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Chapter 1 INTRODUCT ION Medical education in the United States today owes much of its structure to the implementation of many of the recommendations of the 1910 report by Abraham Flexner.l He decried an abundance of non-rigorous proprietary schools and held up as a model the university-based curriculum of Johns Hopkins. Flexner's urging for reform succeeded so well that medical education and medical practice henceforth became solidly grounded in the knowledge and methods of natural science. Most medical schools now build their curriculum on two years of basic science and two years of clinical medicine, taught along disciplinary lines by faculty members who are full-time academics, and who expect the graduates to go on to further training. Major departures from that model have been few and far between, limited largely to development of an interdisciplinary curriculum in the l95Us, and more recently the problem-based and community-oriented approaches to medical education. As medical education settled into a 70-year period principally spent in adding to its science base, American society was changing all around it. Many of the changes were related, at least in part, to medicine's advances, such as a steady expansion in effectiveness against the infectious diseases--immunizations were developed to prevent some and antibiotics were found to cure others. New technologies were developed to improve diagnosis; new drugs and surgical procedures were introduced to improve treatment; an understanding grew of risk factors for disease; systems of life support were perfected to take over for failing organs. But, as infectious diseases became less of a threat, chronic diseases moved into the ascendancy; as newborns were led unscathed through the illnesses of childhood, they lived to incur the diseases of adulthood, including those related to environmental factors and personal habits; as techniques improved to sustain life, concern arose about the quality of that life; and as physicians became more scientific, complaints were heard that they were less compassionate. More physicians are being trained than ever before, but the costs of health care continue to rise steeply and doctors are scarce in the inner city and rural pockets of poverty. Since the Flexner report, our country's entire economic and social system has evolved from one of small scale individualism to organized corporate and government administration. Health care has become an industry--one of the largest, now representing 10 percent of the Gross National Product2 and employing over 7.5 million people, the 450,000 physicians being less than 10 percent of health care personnel.2 Health care decisions no longer derive exclusively from the relationship between an individual doctor and a patient. The 1

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doctor-patient relationship is affected by the complex relations between physicians and the hospitals with which they affiliate, the growing number of salaried physicians and physicians participating in group practice arrangements, and the various private medical insurance programs and federal entitlement programs such as Medicaid and Medicare. Furthermore, roles and responsibilities of physicians in relation to other health professionals continue to change as nurses, physician extenders, and others seek greater professional responsibilities, and as legislative bodies mandate particular roles.3 Another force for change has been the growth of the research programs sponsored by the National Institutes of Health (NIH). Biomedical research has become a multi-billion dollar enterprise. It has produced both an explosion of knowledge and a highly research-oriented faculty in the laboratory-based experimental disciplines, which are dominant over the population-based sciences and the behavioral sciences. Because of an apprehension that our future supply of physicians would be inadequate, and increasing concern for social justice in our country, we have more doctors today than ever before, and they are a more heterogeneous group. Scholarships and low interest loans, federal laws and enforcement efforts, and increased willingness and efforts by admissions committees to enroll qualified women and minorities, have opened the doors of the profession to more students in general and to women, minorities, and those from less wealthy families in particular. Medicare and Medicaid legislation has brought us closer to equity of access to health care, which more and more people view as a right.4 But recently, in the face of economic pressures, the trends toward equity in access to the profession and to health care have slowed. Institute of Medicine members and others, have expressed doubts that some aspects of today's health care system are suitably matched to the preparation of practitioners. Issues that have been brought forward, and that led the Institute to undertake this review and planning effort, include the following. 0 The growing numbers of physicians, the expectations of expanded roles of non-physician health professionals, the desire to assure equity of access to health careers, and the continued presence of medically underserved populations (defined geographically, socioeconomically, or ethnically) raise complex questions which must be dealt with by educational institutions, governments, and society as a whole. How may all of these concerns be balanced and integrated to arrive at a health manpower policy, which would include policies on admissions . to health professions schools and advanced training programs; local, state, and federal subsidy and support for medical education and research; and federal policies relating to immigration, for example. What will the roles of the various health professions be in the future, and how should the education system adapt to changes in role? How do we match numbers and distribution of health professionals to national needs? 2

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o How to assure that the medical education system will educate physicians to be able to address the problems of their patients in the decades ahead, without unduly prolonging the time and resources committed to the medical education process. Included here, for example, are concerns about the aging of the population, the shift in the burden-of-illness toward chronic disease, the growing importance of lifestyle and individual behavior in determining health status, and the importance of primary care physicians in treating mental illness. An orientation to population-based medicine, so as to see significant phenomena and to think of impacts and needs beyond those of the individual patient also is relevant here. o We are in an era in which information is generated at a rate never experienced before--a virtual "information explosion.' now might the education system best prepare physicians to keep abreast of scientif ic advances--prepare them f or lifelong learning? how can computers be maximally utilized for the ef f ective management of information? o In an era of increasingly bureaucratized health care and intensively technological medicine, is a special effort required to preserve the caring function of medical practice--not instead of but in addition to the scientific and technological strengths of medicine? How may the objective of caring be translated into practice; how is it taught and evaluated? o How to train physicians to balance traditional striving for best possible care of a patient with economic constraints which also must be considered; to develop increased sensitivity to economic consequences of medical decisions on the use of resources and to search for more cost-effective means of high-quality care. O How to use the education system to prepare physicians to grapple with questions about what constitutes best care when technology allows for extension of life but of greatly compromised quality. Physicians, individual patients, families, and society as a whole have growing concern about the need for wise and sophisticated decisions to deliberately withhold or withdraw these technologies. Ethical, economic, and personal values all come into play here. o how to prepare physicians to deal with a public increasingly conscious of ethical issues in health care--informea consent, clinical trials, privacy, and the like. o How can the education system assure continued advances in knowledge? How best to train a cadre of physician-researchers? Means to enhance clinical research interfaces between clinical practice and laboratory research need thoughtful consideration. o Questions of responsiveness to the community, and possible conflict of university missions and community missions, arise in many contexts, but appear especially pressing for academic health centers. The fear that teaching hospitals and academic health centers will 3

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collapse under the combined pressures of increased costs, growing competition from community hospitals, reduced direct and indirect federal support, and a disproportionately large share of patients who are unable to pay for their care also must be addressed. Charge to the Planning Committee The Institute of Medicine, which has a tradition of viewing events in the larger perspective when contemplating a new study, wished to examine these various concerns in the context of societal needs now and in the future. A request was made to The Pew Memorial trust to support a planning effort for a comprehensive review of the entire spectrum of medical education. It was in the context of an evolving physician role in a highly complex and changing health care system that the Institute, with the support of the Pew Memorial Trust, undertook this planning effort. A committee was appointed to outline the scope and conceptual framework for a review of medical education. The work of the committee was 1) to identify the perceived deficiencies and strengths in the present system for delivery of health care in the United States, 2) to project future health care needs in light of projections about the way medicine will be practiced and organized in the next 10 to 20 years, 3) to identify elements in the medical education system that have some influence on meeting present and future health needs, 4) to identify the issues meriting highest priority for attention, and 5) to agree on the scope and framework for a significant effort intended to help the education system be most responsive to future health requirements of society. This review and planning effort was undertaken with the full realization that the intrinsic and extrinsic factors which influence medical education have become so intertwined as to be practically inseparable. It also was realized that no single person, group, or institution has the authority to mandate solutions to these major educational issues, institutional issues, and inter-professional issues. The committee's intent was to consider responsibly and rationally the factors relevant to creating a health care system more in tune with the structure of our society and to suggest some educational priorities in the establishment of such a system. Work of the Planning Committee The 18~ember committee undertook a number of activities in order to understand more fully the contexts in which medical education takes place, in which decisions are made about medical education, and in which health goals for the nation are defined. These activities also were intended to help identify national, regional, and local concerns in medical education, to identify further knowledge needed and feasible approaches to acquiring it, and to help develop priorities among the many study issues proposed. 4

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Many persons were consulted informally by the committee and stat f to get the perspectives of teachers, researchers, clinicians, students, educational administrators, government administrators, and foundation administrators, among others. Although too numerous to name individually, we grater ully acknowledge their valuable contributions. A number of previous s tudies were valuable resources . A selec ted lis t of report s on these studies and other relevant books are included in Appendix A. Liaison with the current AAh(: s tudy on General Professional Education for the Physician, described more fully on pa'ge 7, also was established. The staff of the Association of American Medical Colleges (ANTIC) provided valuable assistance, which is gratefully acknowledged. Consultants and Institute staff prepared background papers on subjects selected for detailed examination by the committee. These constitute Part III of this report. Two workshops were convened by the committee--one on Teaching Hospitals and Medical Education and the other on Financing Medical Education. Summaries of those workshops and lists of participants are in Appendix B. With the support of the Josiah Stacy, Jr. Foundation, ~ small conference on The Changing Cost of Medical Education and the impact on the Mix of Students was conducted. The purpose of this conference was to assist the Institute's planning committee in its identification and selection of issues for study. Following the 1 1/2-day conference, a list of study topics was distributed to the participants. They were asked to review the list, add to it if appropriate, and to make judgments on relative priorities. The conference summary, a report on the participant responses about priorities for study, and a list of participants are in Appendix C. Visits were made to two U.S. medical schools: Meharry Medical College was chosen to learn about and highlight issues in the recruitment and education of minority student;. The University of Indiana School of Medicine was chosen as an example of a state- supported school. We were especially interested in its reported succes s in integrating a number of campuses into the medical education program. In addition, the Vice-Chair of the come ittee, while in Israel, took advantage of the opportunity to visit the 1sen Gurion University of the Ne.gev health Sciences (:enter (an example of a co~nmunity-based school) and the Hadassah Medical School of Hebrew University . Appendix 1) contains reports on the f our visits. In order to learn more--in a very preliminary way--of the variety of structures for medical education systems, and how other countries deal with their health manpower needs in the context of medical education, an informal survey of some other countries was made. A letter of inquiry sent to medical/scientific officers in Washington, D.C. embassies and a tabulation of responses are in appendix b. This 5

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survey enabled the committee to identify issues which might be followed up selectively in greater depth, if the Agenda Group decides case studies from abroad would provide useful perspective. One example is the comparative benefits (and problems) of highly selective entrance requirements for medical school (e.g., United States) vs. Open admissions (e.g., Italy). Another topic for possible follow-up and international dialogue is the use, in countries with shortages, of "excess" health personnel from other countries. The planning committee assessed the information gleaned from these various sources in light of their own experiences and knowledge of the published literature. Discussions during six meetings over a 12-month period led to the recommendations that constitute Parts I and II of this report. Rationale for an Integrated Look at Major Issues The first question the committee had to resolve was whether another major study of medical education would be worthwhile. Considerable doubt was encountered about the value of a series of studies on medical education. There were those who adjured us, in effect, "if it ain't broke, don't fix it." They viewed the health care and medical education systems as fundamentally sound and feared that marginal alterations could inadvertently damage the whole. Others, who perceived a need to improve the health care system, expressed skepticism about the ability of the medical education system to influence it. Many other people questioned the need for yet another study of the same subject, and pointed out that the time was at hand for implementation of what we already knew, not more study. Still others considered the subject of medical education too narrow for meaningful analysis. Some believe that the American health care system and American medical education are the best in the world. The education system provides technically competent, honest, responsible physicians. But specif ic system-wide inadequacies exist today, such as steadily rising health care costs and the persistence of medically underserved populations.6 And even if the system were optimal for the present, it would not necessarily be optimal for the future. In the not-too-distant future, with the population aging and the rise of chronic disease, maintenance of maximal possible function, rather than cure, is likely to be the physician's best effort (Chapters 4, 6~.7 Multiple interacting risk factors', rather than straightforward cause-effect relationships, will have greater roles in determining health status.~9 Such trends must be accommodated within medical education, but time is needed until the effect of educational changes will be seen at the level of the health care system. Typically there is a five- to eight-year period from the beginning of medical school studies to entry into independent practice (Appendix F). Thus, the committee 6

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concludes that an integrated look at the medical education system together with education of non-physician professionals who deliver health care, from the perspective of the nation's health care needs in the next 10 to 20 years, could provide timely guidance to those who would make the changes. However, the committee also deems it essential to preserve those parts of the system that have worked well over time and that are likely to continue to be fruitful. To what extent can changes in the educational process be used to solve some of the present concerns centered in the health care system? Although educational changes alone will not solve these problems, it is likely that they will have some effect. By formal course work, by implicit and explicit messages in the words and actions of clinician-teachers, and by informal discussions with mentors and colleagues at many stages of the education process, physicians and other health professionals can learn about care alternatives, career alternatives, and the social implications of one choice over another. Enhancement of awareness of these choices would contribute to the solution of some of the complex and longstanding problems of the health care system. Is there need for further study? Since Flexner's time, many studies on medical education have been published--some by individuals, some by professional organizations, and some by special committees or commissions (Appendix A). These have dealt with modification and improvement in the design and management of premedical, general medical, post-MD (graduate medical), and continuing medical education programs. Recently, the American Medical Association (AMA), in Future Directions for Medical Education,1O examined the concepts and principles governing education for medical practice. However, this report, which offers valuable analysis of medical school and teaching hospital concerns, cautions that it has not addressed in depth "cost and f inancing of medical education; changing ethical principles resulting from new knowledge and technology; interrelationships between government agencies and higher education; . . . expectations of society concerning physician competence; methodologies for evaluating clinical performance; and need for cohesive long-range planning nationally for all levels of medical education." The Association of American Medical Colleges (AAMC) and the Macy Foundation Study Group on Graduate Medical Education completed reports on GME--Graduate Medical Education: Proposals for the Eightiesl1 and Graduate Medical Education, Present and Prospective: A Call for Actibr~l2~- An AAMC study on 'General Professional Education of the Physician and College Preparation for Medicine' (GPEP) is in progress and will be completed in 1984.13 Working groups of the GPEP study have been considering the knowledge and skills physicians must have, as well as the desired personal qualities, values , and attitudes (see Chapter 3~.14 An important component of the charge to these working groups 7

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is the identification of faculty actions that develop and foster the requisite attributes. Several recommendations for actions (by faculty and others) have been advanced by the working groups,l5~16,l7 following a series of regional meetings and deliberations of the working groups. The Project Panel will work on means of implementation of these recommendations during the second year-and-one-half of the three-year study. The AAMC is especially well-suited to look at issues related to internal operations of the medical schools--admissions, for example. Since it is the organization that represents the schools, it is likely that its recommendations will be given serious consideration. There have been a number of manpower studies relevant to medical education. The Graduate Medical Education National Advisory Committee (GMENAC) 1980 reportl8 was concerned with aspects of supply and distribution of physicians, as were On the Status of Health Professions Personnel in the U. S., Third Report to the President and Congress, -Y On the Status of Medical School Faculty and Clinical Research Manpower 1968-1990, and Personnel Needs and Training for ~ . _ Biomedical and Behavioral Research, 1981 Report . Al Of related interest is the recent Institute of Medicine study report Nursing and Nursing Education: Public Policies and Private Actions, which considers the need for federal support of nursing education, means to enlarge the supply of nurses in underserved areas, and reasons for individual career choices by nurses.22 - Similar topics also have been explored in special conferences. The Institute of Medicine sponsored a conference on Clinical Investigations in the 1980s: Needs and Opportunities, which looked into research manpower needs. .A recent Macy conference on Teaching the New Biology went into such issues as teaching methods, evaluation methods, and curriculum goals.24 A conference on Financing Medical Education, at the New York Academy of Medicine, probed "The Cost for Students and the Implications for Medical Practice." And there have been many articles each year on almost all of the issues of concern here in publications such as the Journal of the American Medical Association, the New England Journal of Medicine, and l the Journal of Medical Education. Committee Conclusions The committee has concluded that a major effort is indeed warranted, employing recent reports and ongoing studies as valuable resource s. However, it does not recommend that another broad study of medical education be undertaken. Rather, it is the committee's recommendation that an institutional mechanism more consonant with current decision-making processes be created. This mechanism would provide a forum for discussion by all concerned constituencies; a means to filter and sort major concerns relevant to education of health professionals; and a basis on which to identify areas that require action. 8

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The most important reason for proposing a new approach is the committee's agreement with comments that medical education is too narrow a focus. We agree. Our charge was to plan a study of medical education, and most of the effort in this planning phase emphasized the education of physicians. But the answer to almost every question we asked ourselves depended on decisions about issues such as who would be responsible for aspects of health care of the well elderly and of the chronically ill, who will be advising about health-promoting behavior, and who will be teaching people how to change their behavior ? The first step in rethinking the education system must be a look into the future--in as open a manner as possible and with a minimum of assumptions--to assess what the role of the physician should be. This inevitably leads to a need to project the role of other health professionals--nurses and social workers, to name but two--because physicians do not work alone. Thus, our proposal is to monitor the educational agenda of the health professions in a coordinated manner, and to undertake an early examination of optimal allocation of roles and responsibilities. The committee also believes that the perspective this ef fort would have is extremely important. The interests and needs of the general public served as the starting point in this planning effort, rather than the needs of the health professions as viewed by the health professions. A group bringing together a broad spectrum of health prof essions would be able to question common assumptions and achieve consensus on professional roles and prerogatives. The participation of professional organizations is essential, but the group in its entirety must not be allied with any particular professional interest ; it should be as free as possible from the pressures of representing any particular interest group, and therefore be able to converse with any sector of society in the spirit of free communication and trust. A crucial concern would be how to promote implementation of recommendations (judged by the proposed group to be feasible and promising), whether generated by the group or stemming from other studies. Insight into how to promote and sustain specific reasonable improvements will be important. Without the leverage of money or regulation, power to implement changes must derive from the shedding of light, from the persuasiveness and intellectual rigor of the presentation of the problems and approaches to their resolution. Proposed Plan The ma jar recommendation of this committee is that an Agenda Group on Education of Health Professionals be established to deliberate on how the health professions education system helps or hinders progress toward f uture health goals of our country; to consider the social ~ economic, political, scientific, and educational f orces in our society that act on health professions education; to tell when these forces can be enlisted to implement constructive changes in the education 9

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system; and of equal importance to caution when those forces are acting to undermine a valuable aspect of health professions education. The committee's recommendation is that the Agenda Group - have a broad mandate and broad perspective, encompassing a range of health professions, and that it should have assurance of at least a five-year continuity. Although the Agenda Group would depend heavily upon data generated from a variety of sources, it is the committees further recommendation that as needed the Agenda Group identify specific targeted studies that would help it meet its mandate. These studies could be conducted under the aegis of the Agenda Group, or independently of it. In either case, the Agenda Group would coordinate and integrate the studies, and would seek means to implement recommendations derived from them. During the deliberations of the planning committee, four medical education issues for early attention came to the fore. Listed in priority order, they follow. 1. Financial Pressures on Medical Education 2. The Changing Role of the Physician 3. The Cultures of the Medical Education System 4. The Science Base of Medicine These topics focus on medical education, as does the entirety of this report, because the initial charge to the planning committee encompassed only medical education. However, as indicated earlier, it is the strong recommendation of the committee that the scope of the Agenda Group activities be expanded to include other health professions. Accordingly, the Agenda Group might modify the four suggested studies to include other health professions within their framework. It is our expectation that the information and conclusions brought forth by each of these studies would be most useful if the studies are conducted as a coordinated set of activities; sequencing would be necessary for some studies--how large the science base of medicine is, f or example, will depend on the role of the physician-- other studies could be conducted in parallel. It also is our expectation that as the Agenda Group deliberations proceed, with a scope expanded beyond medical education to include health professions education, additional priority topics for study will be identified. The priority sequence presented here, which was determined by a vote of the planning committee, should not be considered immutable. Several caveats accompany the priority. First is the realization that the expansion of the scope of the Agenda Group beyond medical education to health professions education may change the relative priorities. Secondly, the Agenda Group may wish to modify priorities, in light of the expertise its members provide and the actual timing of its activities--what studies are then available, what developments have occurred since completion of this planning report. The overall theme of the Agenda Group is the interplay of the education systems with their multi-faceted environments. An environment can change quickly, and the priorities should be responsive to these changes. 10

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Additionally, the interest of funding sources may proscribe strict adherence to the suggested priority sequence. This sequence is not intended to be rigid . It is intended to provide helpf ul guidance . The four medical education issues were chosen for different reasons, and their study will serve a number of different purposes. Financial pressures is a topic relevant to the long-range view of the Agenda Group, but it also is of immediate concern. The intent of this s tudy would be to examine the consequences of current f iscal crises and policies and to work toward short-term solutions while also assessing the lessons for long-term policy. The three other themes are closely related to one another and to f inancial pressures. They would help the Agenda Group (and the larger community of educators and policymakers) look toward the future, learn from the past, and illuminate how decisions are made within the education system. Two major public policy questions for each of these priority topics, as selected by the committee, are enumerated below. Chapter 3 presents these and other questions in greater detail. Financial Pressure on Medical Education 1) Should available funds for students be channeled into targeted efforts, such as subsidy programs emphasizing minority and low income groups? 2) Is the present mix of sources of support for medical education adequate and what are appropriate responsibilities (including such issues as payment of indirect costs) of each source (students, state and federal government, private and public third party payers, philanthropy, grants for research, and cross-subsidies from other units of the university) ? The Changing Rule of the Physician 1) What are the implications for the future role of physicians of the increasing supply of physicians, increase in number and proportion of elderly, scientific advances, changes in burdens of illness, increased interest in health promotion and disease prevention, and changes in numbers and kinds of non-physician providers? 2) What outcome measures can be used to evaluate quality of physician performance? Valid outcome measures would be needed to determine which selection procedures and which innovative approaches to medical education are most likely to produce physicians well suited to their various future roles. The Cultures of the Medical Education System Behind each of these issues are questions of power and decision- making wi thin the educat ion sys tem. 11

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l) What are the implications for educational values and messages of the organization and financing of academic medical centers? 2) How do the values and priorities implicit in the traditional socialization process by which a medical student becomes a physician relate to the shifting goals of medical education? The Science Base of Medicine 1) What is the Science base needed for the future practice of medicine and what is the general education required of future physicians? 2) When in the educational sequence should particular aspects of the science base be taught--and how can better integration of the teaching in the several institutions involved be achieved? The committee believes that all of these topics deserve priority consideration and clarification; some will need new research; all require thoughtful attention and considered action. The topics differ considerably in terms of their susceptibility to various research methodologies. For some, there are existing instruments and experimental designs that can be applied so as to minimize threats to reliability and validity. In many cases, qualitative research methods can be applied, but in others, the lack of a clear conceptual framework inhibits more formal inquiry. The basis for these recommendations and more details about the proposed studies are presented in the following chapters. The Agenda Group is discussed in Chapter 2. The medical education study issues are presented in Part II (Chapter 3~. 12

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REFERENCES Flexner, A. The Flexner Report on Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the . Advancement of Teaching. Washington, D.C.: Science and Health Publications, 1960, Original printing, 1910. '. U. S. Department of Health and Human Services, Public Health Service. Health United States, 1982. DHHS Publication No. (PHS) 83-1232. Washington, D.C.: U.S. Government Printing Office, 1982. 3. Roemer, M. I. An Introduction to the U.S. Health Care System. New York: Springer Publishing Company, 1982. 4. Jonsen, A. R. The Rights of Physicians: A Philosohica1 Essay. Andrew W. Mellon Foundation, June 1978. 5. Table 67, Reference #2. 6. Department of Health and Human Services, Public Health Service, Health Services and Resources Administration, Bureau of Health Professions. Selected Statistics and Health Manpower Shortage Areas (as of September 30 , 1982 ~ . Rockville , Md .: Of f ice of Data Analysis and Management, 1983. 7. Institute of Medicine. The Elderly and Functional Dependency. Washington, D.C.: Institute of Medicine, 1977. NTIS accession no. HRP-0024772. 8. Institute of Medicine. Healthy People, The Surgeon General's Report on Health Promotion and Disease Prevention, Background - papers. DHEW (PHS) Publication No. 79-55071A. Washington, D.C.: U. S. Government Printing Of f ice, 1979. 9, Tnot] tilt" Of M-d ~ nine. Health and Behavior Frontiers of Research in the Biobehavioral Sciences . Washington, D. C.: National Academy . . Press, 1982. 10. American Medical Association. Future Directions for Medical Education. A Report of the Council on Medical Education. Chicago, Illinois: American Medical Association, 1982. 11. Association of American Medical Colleges. Graduate Medical Education: Proposals for tt~ Ii. Washington, D.C.: ~;= _ is, 1980. 12. Josiah Macy Jr. Foundation. Graduate Medical Education Present and Prospective: A Call for Action. Report of the Macy Study Group. New fixation, 1980. 13. Association of American Medical Colleges. An Overview of the General Professional Educ ~ PreDaration for Medicine and Questions that Should be Addressed. . Washington, D. C .: AAMC, 1982. 13

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14. Association of American Medical Colleges. Charges to the Working Groups on the Essential Knowledge, the Fundamental Skills and the Personal Qualities, Values and Attitudes that Comprise the General - Professional Education and College Preparation for Medicine. Washington, D. C .: AAMC, 1982. 15. AAMC Working Group on Essential Knowledge. Panel . Washington, 1). C .: AAMC, 1983. 16. AAbIC Working Group on Fundamental Skills. Panel. Washington, D. C .: AAMC, 1983. - Final Report to the Final Report to the 17. AA1IC Working Group on Personal Qualities, Values, and Attitudes. Final Report to the Panel. Washington, D.C.: AAMC, 1983. 18. U.S. Department of Health and Human Services. Summary Report of the Graduate Medical Education National Advisory Committe, Volume DHHS Publication No. (HRA) 81-651. Washington, D.C.: U.S. Government Printing Office, 1981. 19. 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, I).C.: U.S. Government Printing Office, 1982. 20. U.S. Department of Health and Human Services. NIH Program Evaluation Report on the Status of Medical School Faculty and Clinical Research Manpower, 1968-1990. Washington, D.C., 1981. 21. Committee on a Study of National Needs for Biomedical and Behavioral Research Personnel. Personnel Needs and Training for Biomedical and Behavioral Research. The 1981 Report. Washington, D.C.: National Academy of Sciences, 1981. 22. Institute of Medicine. Nursing and Nursing Education: Public Policies and Private Actions. Washington, D.C.: National Academy Pres s, 1983. 23. Institute of Medicine. Clinical Investigations in the 1980s: Needs and Opportunities. Report of a conference sponsored by the Andrew Mellon Foundation, May 29-30, 1980. Washington, D.C.: National Academy Press, 1981. 24. Friedman, C. P. and Purcell, E. F., eds. The New Biology and Medical Education: Merging the Biological, Information, and Cognitive Sciences. New York: . Josiah Macy Jr. Foundation, 1983. 14