ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2530 RIDGE AVENUE - EVANSTON, ILLINOIS EVANSTON: DAVIS 8-9505 February 24, 1961 CHICAGO: BROADWAY 3-4350 Honorable John #, Fogarty House of Representatives Congress of the United States Washington, BD, C. Dear Congressman Fogarty: Thank you for your letter of February ist and for the copies of bills relating to health which you so kindly sent to me, All of us in the Association of American Medical Colleges deeply appreciate your interest in these problems which relate to the health of our people and we are eager for our representa- tives to meet with you in order that we may exchange ideas about some of these problems, Enclosed is a copy of the formal statement which was adopted without a dissenting vote at a recent meeting of the Institutional Membership of our Association which speaks for all of the medical colleges, I woule like to touch briefly on the major features of our recommendations. Matching construction grants for education facilities of the medical schools is recommended as our number one priority. These funds are needed not only for the establishment of new medical schools but for the expansion, moderni- zation and replacement of existing medical schools, We feel that the favor- able matching relationship recommended by our Association will be a real ine ducement to Universities to take these necessary but very costly actions, Scholarship aid to medica) students is recommended as our second priority, This will have the greatest impact in the recruitment of qualified applicants if it is applied on as broad a base as possible, Therefore, we recommend that scholar- ship grants be made to all of the medical schools on the basis of $500 per reg- istered medical student, The schools would determine the relative merit and need of each student and would allocate funds accordingly with no student receiving more than $2,500 per year of Federal funds, Students in ne financial need would receive no scholarship support. As our third priority we recommend that the Federal government pay the full cost of the medical research which it supports at the Universities, This point has peen so well documented by various studies in the past that it requires no further amplification. In the fourth place, we recommend the expansion of Federally supported research and research training as rapidly as funds can be made available and wisely spent, We believe that this program has been administered in an extremely effective fashion and we wish to express our deep appreciation for this most significant program. Honorable John EH, Fogarty February 24, 1961 me om In the £ifth place, we recommend that a mechanism be found for the Federal government to give general support for medical education, Many medical schools now have financial resources too limited to enable them to maintain a program of excellence for their present numoer of students, They would find it impossibie, therefore, te take on the Tinanciel obligations of additional students. Many universities, already overburdened and in financial difficulties, will find it impossible to establish new medical schools unless they have real hope of Federal Support to assist in carrying these high cost programs. In the sixth place, we wish to recommend that the programs discussed above should be coordinated since they obviously are all closely related, We wish to commend the fine working relationship which exists between the medical schools and the United States Public Health Service and the National Institutes of Health. it is our hope that some of the officers of the Association of American Medical Colleges and members of its committee which has made a study of the special needs referred to above might have the privilege of meeting with you in the near future to discuss these problems, I will be calling you shortly in the hope that we might be able to arrange an appointment. in the meantime if you wish to get in touch with me for any reason, I can be reached at the University of Washington School of Medicine Dean's Office in Seattle, telephone number LéAkeview 4-59000, extension 3448, If for some reason you cannot reach me, Dr, Ward Darley, Execu- tive Director of the Association, is available at the Association offices, 2530 Ridge Avenue, Evanston, Illinois. The telephone number there is DAvis &-58o505, Many thanks again for all your interest and for all the help which you have al- ready given to our medical schools, I look forward to meeting you in the near future, With every good wish, Sincerely yours, “ G. N. Aagaard, M, 5. President GNA: jm cc: Dr, Ward Darley Association of American Medical Colleges Proposals of the Support of Medical Education by the Federal Government Adopted by the Institutional Membership January 11, 1961 Chicago, Illinois PREAMBLE The American people are deeply concerned about health. Responding to this concern as a matter of national policy, the Federal Government in the past fifteen years, largely through the Department of Health, Education and Welfare, has joined state and local governments, health and educational institutions, voluntary health agencies, private philanthropy, and industry in meeting two especially critical needs in the attack on disease: the construc- tion of hospital and other facilities for the care of patients (Hill-Burton program), and the support of medical re- search (National Institutes of Health). Expenditures by the Government in support of these two programs represent investments in the health of the nation which pay rich dividends, as has been amply documented. It is imperative that these programs be con- tinued and developed further. Health service facilities and medical research have made possible dramatic progress in the prevention and treatment of disease. A block to the effective use of new knowledge and to the pursuit of further knowledge is the increasing shortage of personnel in the health professions, particularly doctors. This block can be removed only by the improvement and expansion of the nation’s system of medical education. The critical nature of this problem has been defined in five reports prepared in recent years by advisory groups of non-government consultants.* These authoritative studies show that by 1975 the nation will need to train about fifty per cent more physicians than in 1960 just to maintain the current ratio of physicians to popu- lation, a ratio generally accepted as a minimum requirement. Because of the time required to improve and develop facilities and faculties and to take doctors through the full cycle of five to nine years of professional training, action to improve and expand programs of medical education must be taken at once. Otherwise, the nation faces a very serious reduction in its ability to control and cure disease and our people will not have available the medical service they want and expect. Since the problem of medical manpower can be solved only by prompt and comprehensive national effort, it is appropriate that medical schools and their parent institutions outline the basic requirements which to them seem necessary to accomplish this national objective while preserving the traditional freedom of the educational institutions. To this end, the Association of American Medical Colleges is suggesting principles of a Federal program of assistance to medical education which have been generally agreed to by its members. The program presented in this statement outlines those measures that the medical schools believe neces- sary if existing programs of medical education are to be maintained at an adequate level of quality and if there is to be a sufficient expansion of our facilities to provide the number of well trained medical graduates that the nation requires. In considering needs of medical education, it is important to understand the variety, complexity and inter- relationships of activities involved in the training of medical personnel. This is especially true in relation to the three components of medical education: teaching, research, and service. The inseparable nature of these three functions has led to the ‘tmedical center’? concept as a more realistic characterization of medical education than the too frequently held concept of the medical school, the teaching hospital, the research program, and community health services as activities independent of each other. However, the two major Federal support programs - for medical facilities and for medical research - while understandably directed toward specific restricted objectives have complicated the conduct of medical education by failing to recognize that research and service are integral functions with teaching. Thus, the need for service facilities and the need for research facilities in a medical education environment have been considered independently by the government, and no provision at all has been made for teaching facilities, although teaching is basic to both service and research. The medical center typically has as its nucleus a medical school for the undergraduate training of can- didates for the M.D. degree. Essential to this program is a strong faculty in the basic health sciences. Such * 1952 Report of the President’s Commission on the Health Needs of the Nation 1958 Final Report of the Secretary’s Consultants on Medical Research and Education 1959 Report of the Surgeon General’s Consultant Group on Medical Education 1960 Report of the Committee of Consultants on Medical Research to the Subcommittee on Departments of Labor, Health, Education, and Welfare, of the Committee on Appropriations, United States Senate, Eighty-Sixth Congress, Second Session 1960 The Report of the President’s Commission on National Goals scientists can be retained and can be fully effective only when they are given broad opportunity for research activity -- teaching is barren in the absence of an environment conducive to the vigorous pursuit of new knowledge. These same faculty members are also calledupon to train another important group of students -- the future special- ists in their fields who are Ph.D. candidates within the graduate program of the parent university. This is a vital function, particularly for the production of medical teachers and research personnel. Likewise, these faculty mem- bers in many situations are called upon to teach basic sciences to dental students, nursing students, and para- medical personnel. They must also participate in clinical teaching conferences in support of both undergraduate and graduate medical education. The medical center concept is particularly pertinent in the teaching of the clinical specialties. Clinical teaching is conducted in relation to patient care, and a high standard of patient care is necessary for good teach- ing. A core of full-time teachers is required to give continuity and responsible direction and supervision to patient care and the related teaching. The teaching hospital of a medical school, then, whether directly operated by the school or affiliated with it, is an important component of the medical center, Also, opportunity for research is important to the clinical teacher and to good clinical teaching just as is true in the basic sciences. The clinical faculty, in addition to its responsibility for teaching of M.D. candidates, is becoming in- creasingly responsible for graduate training of doctors -- interns, residents, and fellows. Medical graduates are tending more and more to seek advanced clinical training in hospitals operated in conjunction with medical schools because of the educational orientation of the training. These teaching and training responsibilities put a heavy burden on the schools and their teaching hospitals for which support is required. Finally, a new and growing responsibility of medical schools is to provide leadership in coordinating medical services within their area andin providing post-graduate and specialized training opportunities for practic- ing physicians. These various activities of the medical school beyond the four-year M.D. program must be understood and recognized -- and support of medical education must be provided in keeping with the concept of the medical center. The proposals that follow represent the initial steps that the Association of American Medical Colleges believe should be undertaken in order to accelerate the ability of this nation’s system of medical education to produce the numbers, categories, and quality of the professional and technical personnel required to meet the health needs of a population that is not only growing in size but also in medical understanding. These proposals cover only the needs of the nation’s existing schools of medicine and the need for new schools. The Association of American Medical Colleges recognizes the importance of the health professional areas other than medicine and also of the research and research training that is done in institutions other than schools of medicine. Any provision which the Federal government makes to meet the needs of educational and research activities that take place outside the medical school and its research and service facilities should be over and above the recommendations in this statement. While all of the proposals require implementation, funds for construction are given first priority because itis the inadequacy of existing facilities that is the primary obstacle to the over-all development that is needed. Until steps are taken to solve this problem, little will be accomplished by efforts to increase medical school faculties or student enrollments. Students and teachers must have suitable places in which to work, including classrooms, laboratories, libraries, hospitals and clinics. I. Matching funds for modernization and expansion of existing schools and the construction of new schools. A. The Need In the fall of 1959 the Surgeon General’s Consultant Group on Medical Education reported that to main- tain this nation’s present ratio of physicians to population, by 1975, 3,500 more physicians must be graduating each year than is presently the case. This means, with due allowance for drop-outs between admission and graduation, that by 1970 this nation must provide an increase of approximately 4,000 first year places in its schools of medicine. A survey in the fall of 1960* discloses that 1,700 of these additional first year places can be created by the full modernization and expansion of existing schools. The remaining 2,300 must come from the es- blishment of new schools. Therefore, the provision of funds that will provide for both of these approaches will permit enrollment increases that can be both prompt and continuous. The nation’s schools of medicine, colleges and universities of themselves do not have the resources to finance the necessary modernization expansion and new development. Most of the needed money must come from the Federal government. B. Policy Since medical education serves many national purposes and since its strength comes through the diversity * Medical Education in the United States and Canada, Wiggins, W.S., Leymaster, G.R., Taylor, A.H., ad Tipner, Anne, JAMA 174: 1425-1431 i. of local ownership and control, the Association of American Medical Colleges favors both federal and local Participation in the construction of medical schools and their related research, library, hospital and clinic facilities. Federal matching funds should be provided under conditions that will: 1. be sufficient in amount to encourage action that is both prompt and adequate; 2. encourage the modernization and expansion of existing schools; 3. encourage academic institutions not presently involved in medical education to plan and develop new schools; 4. encourage an institution’s continuing effectiveness in maintaining diversity in its sources of financial support; 5. recognize the essential unity of medical education and research by identifying the support of one with the other; 6. recognize the indispensability of the library, the university hospital, and clinic to medical research and education. C. Proposals 1. As an initial step, the Association of American Medical Colleges recommends that the Congress pass enabling legislation covering a ten year span that will provide matching funds for the full moderniza- tion and expansion of existing programs in medical education and the development of new programs. 2. It is recommended that the first appropriation measure cover a three year period with a provision for annual amendment, depending upon the continuing study of needs and of the amounts that can be ex- pended to the best possible advantage. As a basic appropriation for this three year period, the Asso- ciation recommends: a. that $50 million a year be appropriated for grants for the full modernization, expansion or replace- ment of the educational, research, and library facilities of existing schools of medicine. Tf an increase of 5 per cent or more is made for the enrollment of first year medical students, the federal matching should be three dollars for one; if there is less than a 5 per cent increase in first year places, the federal matching should be three dollars for two; b. that $50 million a year be appropriated for grants to existing schools of medicine for the moderniza- tion and expansion of those teaching hospitals and clinics that are their primary base for clinical teaching and research, the granting of such funds to be upon application made by the medical school or university. The matching formula for such grants should be one Federal for one local dollar; c. that for the first year, $50 million be appropriated for grants for the construction of new schools, including research facilities and teaching hospitals and clinics. Federal funds should be provided upon a 3 to one basis; d. that $300,000 per year be appropriated for grants, up to $50,000 to an academic institution that wishes to study the feasibility of establishing a new school. Financial aid to students of medicine. = encia’ ald to students of medicine. A nation wide study of the students graduating from medical schools in 1959 showed that at least one- third had important financial problems. The Association of American Medical Colleges believes that to insure an adequate number of medical students, the most crucial need at this time is for non-refundable educational gtants (pre-doctoral medical 2. not in any way limit the ability of a student to attend the school of his choice; Ill. IV. Vi. 3. not impose restrictions upon the student’s freedom to obtain postgraduate training or pursue a Career of his choice; 4. be made available as a lump sum grant to each school, the amount to be determined by the number of enrolled medical students. Five hundred dollars per student is suggested; 5. be administered by each school in accordance with its particular needs and circumstances with the provision that all such funds be used in direct aid to medical students, that up to $2,500 per student be the maximum of the Federal fellowship allowed in a single school year, and that no restrictions be placed upon the freedom of the school to use funds for student aid from other sources. The provision of the full cost of project-supported research and research training. The Association continues to recommend that grants from the National Institutes of Health for the support of research and research training permit the payment of full costs based upon a formula that will allow for variations in the costs from institution to institution. The support of research and research training. The Association of American Medical Colleges recognizes that the Federal Support of research and re- search training has lead to great improvement in the health of both the nation and of the world and recommends that this support be continued. One of the major objectives of the Association’s proposals for funds for the remodeling and expansion of existing schools and for the construction of new schools, as well as its recom- mendations for full reimbursement for the cost of research and research training, is to strengthen the basic capacity of the nation’s schools of medicine to conduct these activities. The Association therefore recommends that, as the result of constant study, each year’s appropriation for research and research training continue to be adjusted to the national need, to the availability of facil- ities and scientific personnel, and to the amounts of money that can be spent wisely and efficiently. General support of medical education. The program of assistance to medical education offered in the foregoing sections is essential to modern- ize and expand the physical facilities of the medical schools of the nation, to assist in the creation of new schools, and to make it possible for young men and women of intelligence and character, even though of modest means, to secure a medical education. But this program alone will not provide enough physicians to meet the needs of the nation. A strong sys- tem of medical education requires adequate financial support that is continuing and stable. Universities with budgets already under great stress will be unable to maintain, improve, or expand their existing medical pro- grams or to establish new medical schools or new educational programs unless sources of additional operating funds are found. Since this is a matter of vital concern to the entire nation, the Association of American Medical Colleges believes it is reasonable and proper that the Federal government should provide together with other national and local sources the needed additional operating funds. All such funds should be made available in a manner which will assure the continuation of full institutional control of medical education. Administration The Association of American Medical Colleges believes that the close coordination of Federal programs that support medical education is essential. The Association takes cognizance of the long and effective working relationships existing between the medical colleges and the Department of Health, Education and Welfare, particularly the U.S. Public Health Service and its National Institutes of Health and expresses its hope that the future Federal support of medi- cal education will be administered in the same enlightened manner, with the full utilization of non-federal consultants, that has characterized the past.