§jrJ)rJ)'

§(1)

0..

"51..8:...... '

~!'"0 '(1)'u';:l'

'"0,

8·0..(1)\-;

(1)

.Do......

......oZ

ao<.l:11::(1)

a8oQ

ASSOCIATION OF

AMERICAN

MEDICAL COLLEGES

MINUTES

OF THE PROCEEDINGS

Sixty-Second Annual Meeting

FRENCH UCK, INDIANA

October 29-30-31, 1951

TheJoumalof MEDICAL EDUCATION

MAY, 1952 PART TWO

Office of the Secretary

185 North Wabash Avenue

Chicago 1, Illinois

ao<.l:1

Sixty-Second Annual Meeting

Association of American Medical Colleges

French Lick Springs Hotel, French Lick, Indiana

October 29-30-31, 1951

MONDAY. OCTOBER 29. 1951

(President Arthur C. Bachmeyer presiding)

Opening Address-Charles Dollard, president, Carnegie Corporation of NewYork. (Published in the May 1952 issue of the Journal of MEDICALEDUCATION Part one, page 161.)

Naming of Nominating Committee.._. __ __. .__ ._.. _. __ .. .__ __ page 7

Meeting of Six Round Table Discussion GroupsNames of Participants __..__.. __ _.. ._ _ --.-- --------------.-.-----.---.--.-.page 7

(For summaries of the discussions see page 80.)

Presidential Address-Arthur C. Bachmeyer. (Published in January 1952 issueof the Journal of MEDICAL EDUCATION page I.)

Open Hearings on Annual Reports of Standing CommitteesNames of Members of Committees _ __ .._..__ . _ ._.. __ . . .. page 7

(For full reports as revised and accepted see page 35.)

Problems of the Internship Placement ProgramSummary ..__ _.._ _ __ __ __ . .__ . ._.. ..__..page 7

Presentation of Borden Award in the Medical Sciences for 1952. ._..__ .. page 8

After-Dinner Address-Herman B. Wells, president, Indiana Universify _ page 9

TUESDAY. OCTOBER 30. 1951

(President Arthur C. Bachmeyer presiding)

Symposium on the Conference on Psychiatric Education held at Ithaca, N. Y.,June 21-27. 1951. (Published in May 1952 issue of the Journal ofMEDICAL EDUCATION Part one. page 166.)

62ND ANNUAL MEETING 3

Summary of Round Table Discussions . . ..__ ._._ page 80Resolutions _ _ . . .. . . ._ _ page 91

WEDNESDAY. OCTOBER 31. 1951

{President Arthur C. Bachmeyer presiding}

MINUTES OF THE PROCEEDINGS

The final action of the meeting was the induction of Dr.George Packer Berry as President of the Association

Executive Session and Business Meeting

Roll Call __ _ .._ _ page 10Introduction of New Deans _ page 10Approval of Minutes of the 6Ist Annual Meeting --..-..-.-- --page 10Work of the National Society for Medical Research-Ralph Rohweder..__.. page 10Progress Report: Survey of Medical Education-John Deitriclc _ _.. ..__ page IIWorle of the Federation of Licensure Boards-Walter E. Yest _ __ __ page 12Work of the Council on Medical Education and Hospitals of the American

Medical Association-Donald G. Anderson _page 13Report on "A Comparative Study of Essay and Objective Examinations for

Medical Students"-John T. Cowles, John P. Hubbard _ _page 14Report on "Recent Advances in Education in Physical Medicine and Rehabili-

tation in the United State~" by the Council on Physical Medicine andRehabilitation of the American Medical Association page 17

Report of Its First Year's Work by the National Interassociation Committeeof Internships._ _ _ _. ._page 18

Report on the Year's Worle of the National Fund for Medical Educatiori-Chase Mellen Jr•................................................_ -.- - _._ ..__ page 20

Report on the Student American Medical Association-Russell F. Staudacher - -..- -- page 21

Report of the Chairman of the Executive Council-Joseph C. Hinsey_ __ __ page 22Actions Taken on the Recommendation of the Executive CounciL __..__ page 25Report of the Secretary-Dean F. Smiley __ _.. _ _.. _ page 25Report of the Managing Editor of the Journal of MEDICAL EDUCATION-

William Swanberg _ _ __ _ _ __ _.._..__ .page 26Report of the Director of Studies-John M. Stalnaker _ _ _ page 28Report of the Treasurer-John B. youmans _ __ ..__. -.----..-page 30

Reports of Chairmen of the Standing CommitteesFull Reports as Revised and Accepted __.._._..__ _ _ _..page 35

Committee on Audiovisual Aids, p. 35; Committee on Environmental Medicine,p. 38; Committee on Financial Aid to Medical Education, p. 56; Committee onVeterans Administration-Medical School Relationships, p. 62; Committee onForeign Students, p. 65; Committee on Internships and Residencies, p. 69; Plan-ning Committee for National Emergency, p. 73; Committee on PostdoctoralEducation, p. 73; Committee on Public Information, p. 74; Committee on Stu-dent Personnel Practices, p. 74.

Report of the Nominating Committee_ _ _ _ __.. ..__ _ page 77Actions at Meeting of New Executive CounciL._ _ _. __ . .__.__._page 77

Dinner Address-Sir James Spence, Durham University, England __ __.. page 77

4

ao<.l:11::(1)

a8o

Q

ao<.l:1

!JnlroJuclion 10 lhe minuled

T HE MAy ISSUE of the Journal of MEDICAL EDUCATION covers the highpoints of 62nd Annual Meeting of the Association. Details of the reports,committee meetings, resolutions and othen activities of the French Lickmeeting follow in this Journal Supplement.

A wider distribution of the Minutes to all on the mailing list of theJournal was last done 1934, and this issue merely revives a practice of thosetimes.

We hope it will be possible to make this kind of publication an annualprocedure, following approximately within two months of the meetingdate, for the following reasons:

1. The Minutes help bring the meeting to those who were unable toattend and stimulate their contribution to discussions in Journal pages.

2. A means is provided for acquainting meeting participants with whatoccurred in sections they were unable to attend.

3. The Proceedings give an overall picture of the range of problemsfacing medical educators today.

4. The- Minutes outline the work of the Association and indicate theconstructive efforts being made to solve these problems.

2>ean :J.. Smile,!Secretary

ao<.l:11::(1)

a8o

Q

OFFICERS OF THE ASSOCIATION

1950-1951

President: ARTHUR C. BACHMEYER University of Chicago School of Medicine

President-Elect: GEORGE PACKER BERRy Harvard Medical School

Vice-President: EDWARD L. TuRNER University of Washington School of Medicine

Secretary: DEAN F. SMILEy 185 N. Wabash Ave., Chicago 1, nIinois

Treasurer: JOHN B. yOuMANS Vanderbilt University School of Medicine

ExecutIve Council

JOSEPH C. HINSEY, Chairman Cornell University Medical College

ARTHUR C. BACHMEYER University of Chicago School of Medicine

GEORGE PACKER BERRy Harvard Medical School

WARD DARLEY University of Colorado School of Medicine

VERNON W. LIPPARD University of Virginia Department of Medicine

C. N. H. LONG yale University School of Medicine

EDWARD L. TURNER......•.•........••..•....•.•...University of Washington School of Medicine

Staff

DEAN F. SMILEy Secretary; Editor, Medical Education

JOHN M. STALNAKER Director of Studies

DAVID S. RUHE Director, Medical Film Institute

WILLIAM SWANBERG Managing Editor, Medical Education

ao<.l:11::(1)

a8oQ

Nominating CommitteeThe Nominating Committee was named

by President Arthur Bachmeyer as fol­lows: Walter A. Bloedorn, chairman;Loren Chandler; John D. Van Nuys.

Round Table Discussion GroupsSix round table discussions were held.

Subjects, chairmen and discussion groupswere:

1. Regional Hospital Plans and Con­tinuation Education of Physicians-Ru­dolph H. Kampmeier, chairman; EdwardH. Hashinger; Kinloch Nelson; HarryTowsley; Samuel Proger.

2. The Threat of Large-Scale ResearchPrograms to the Quality of Medical Edu­cation-Richard Young, chairman; Max­well M. Wintrobe; James Faulkner.

3. Medical Teaching on the AmbulantPatient-David Barr, chairman; StanleyDorst; Lester Evans; Jacob Horowitz.

4. Group Practice in Support of MedicalEducation-Albert C. Furstenberg, chair­man; Charles L. Brown; Willis M. Fowler;Julian D. Hart; Charles F. Wilkinson.

5. The Influence of Medical Care Insur­ance Plans on Teaching Material-LorenChandler, chairman; Currier McEwen,Paul Hawley; Lowell Coggeshall; EdwardTurner; Francis Hodges.

6. The Means of APPTaisal of the Medi­cal Student's Progress and of the Effec­tiveness of Teaching-Robert Moore,chairman; C. N. H. Long; John Stalnaker;Thomas A. C. Rennie; Ralph Tyler.

Open Hearings on AnnualReports of Committees

Open hearings on annual reports ofcommittees were held as follows:

1. Audiovisual Education - Chairman,Walter A. Bloedorn; J. S. Butterworth;Clarence de la Chapelle; Joseph Markee;Aura Severinghaus.

2. Environmental Medicine - Chair­man, Duncan W. Clark; Jean A. Curran;Harry F. Dowling; William W. Frye;David Rutstein; Leo Simmons; ErnestStebbins.

3. Financial Aid to Medical Education

62ND ANNuAL MEETING

-Chairman, George Packer Berry; Ar­thur C. Bachmeyer; Walter A. Bloedorn;Melvin A. Casberg; Ward Darley; JosephC. Hinsey; Vernon Lippard.

4. Foreign Students-Chairman, Fran­cis Scott Smyth; Maxwell E. Lapham;C. N. H. Long; Harry A. Pierson; Aura E.Severinghaus; Edward L. Turner; Fran­cis A. Young; E. Grey Dimond; FrodeJensen.

5. Internships and Residencies-Chair­man, John B. Youmans; D. W. E. Baird;W. A. Bloedorn; Warren T. Brown; CoyC. Carpenter; L. R. Chandler; J. A. Cur­ran; Stanley Dorst; Reginald Fitz; Max­well E. Lapham; H. C. Lueth; John McK.Mitchell; Francis J. Mullin; C. J. Smyth·Wesley Spink; R. Hugh Wood. '

6. Planning for National Emergency­Chairman, Stockton Kimball; GeorgePacker Berry; John Z. Bowers; MelvinCasberg; Edward L. Turner.

7. Postdoctoral Education-Chairman,John Truslow; George N. Aagaard; Ken­dall Corbin; Aims C. McGuinness; CharlesWilkinson.

8. Public Information-Acting Chair­man, Loren Chandler; George N. Aagaard'Franklin D. Murphy; Ralph Rohweder;Dean F. Smiley; John D. Van Nuys.

9. Student Personnel Practices-Chair­man, Carlyle Jacobsen; George PackerBerry; D. Bailey Calvin; John Deitrick;Thomas Hunter; Richard H. Young.

10. Veterans Administration - MedicalSchool Relationships-Chairman, R. HughWood; Harold Diehl; Reginald Fitz; B. O.Raulston.

Problems of the InternshipPlacement Program

At a meeting of all member representa­tives, called for discussion of "Problemsof the Internship Placement Program"the following letter was read: '

National Interassociation Committeeon Internships

October 25, 1951To the Dean and Hospital Administrator:

The NICI is anxious to have full stu­dent participation, understanding andgenuine support of the matching plan for

7

ao<.l:11::(1)

a8o

Q

internship appointment. In order to allowmore time for student consideration, thedeadline for the receipt of student agree­ments is being extended to November 15,1951. This can be done without inter­fering with the other scheduled dates ofthe plan. For the benefit of the studentsand the hospital, his credentials shouldbe sent to the participating hospitals towhich he has applied as soon as possibleafter his student agreement is signed.Many student agreements have alreadybeen received.

Students from a number of medicalschools met in New York on October 21to discuss thl:' matching plan. They raisedobjections, especially that the plan hadbeen adopted without student consulta­tion. There were many misunderstandingsabout how the plan would work, and re­sentments at pressures they believed werebeing imposed on them.

The majority of the students attendingthe New York meeting, however, favoredthe fundamental idea of a matching plan.The mCI will give full consideration toproposals from students suggesting feasi­ble modification leading to the improve­ment of the plan, if the student proposalsare presented promptly and with sufficientspecificity to permit careful study. Obvi­ously no changes can be made, however,without the approval of both the studentsand hospitals.

Information about the matching planhas been confusing on the point of confi­dential statements between student andhospital. Such informal agreements be­tween some students and some hospitals,whether unwise or not, will undoubtedlybe made. They will be valid, however,only to the extent that they are supportedby the official confidential rating blankssubmitted by both hospital and student.

Hospitals should appreciate that stu­dents resent what they consider unfairpressures which force early commitments.Frank exploration of mutual interests,however, is within the spirit of the plan,although actual commitments limiting thefreedom of each should not be enteredinto. Since both hospitals and studentswill have full weight given to their pref­erences in accordance with the order ofmatching, prior agreements are notnecessary.

Sincerely yours,F. J. Mullin, Chairman

The following resolution was passed:"That the delegates of the A.A.M.e.

work through the mCI to obtain an order

8

of matching, which, it is believed, willwork to the best advantage of and be ac­ceptable to, the students and the hospitals,that the students' suggestions be carefullyand fully considered in reaching this de­cision and that the NICI be assured of thefull and active support of the A.A.M.C. inwhatever action it judges to be best."

The Borden AwardThe nominating address for the Borden

Award in the Medical Sciences for 1951was made by David P. Barr as follows:

Five years ago, in 1946, the BordenCompany Foundation suggested for con­sideration of the council of the Associa­tion, establishment of an award to beadministered by the Association. Thiswas to consist of $1,000 and a gold medal,to be granted each year in recognition ofoutstanding research in the medical sci­ences by a member of the faculty of amedical school which itself is a memberof this Association.

The list of previous recipients is adistinguished one: 1947, Vincent duVigneaud, professor of biochemistry atCornell; 1948, George N. Papanicolaou,professor of clinical anatomy at Cornell;1949, Fuller Albright, associate professorof medicine at Harvard; 1950, Gerty T.Cori, professor of pharmacology at Wash­ington University.

Your committee this year was composedof J. S. L. Browne, C. N. H. Long, HarryP. Smith, Edward West and myself. Wehad the exciting but difficult task ofconsidering the merits of 17 worthy can­didates proposed by members of the As­sociation. As chairman of your committee,I have the honor of announcing its selec­tion and nomination; Dr. Edwin BennettAstwood, research professor of medicineat Tufts Medical School.

Born in Bermuda, he is a product ofeducation in his native island, Canada andthe United States. He received the de­grees of Bachelor of Science from Wash­ington Missionary School, Doctor of Phil­osophy from Harvard, and Doctor ofMedicine from McGill University. He hasbeen a surgical pathologist at Johns Hop­kins Hospital, an associate in obstetricsat Johns Hopkins University,· pharmaco­therapeutist at Peter Bent BrighamHospital, endocrinologist at the New Eng­land Center Hospital and physician atBoston Dispensary.

In these days of specialization ,!nd over­specializatio~it is.refreshing to encountera man of broader comprehension who canbe at once a biologist, chemist, pharma-

ndINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

aBoQ

cologist, obstetrician and internist, andeven an endocrinologist.

Dr. Astwood has demonstrated surpas­sing ability to bring together as gristfor his mill ingredients from many sources,and to produce from the mixture loavesof unique quality. His investigations havebeen numerous and diverse. Ever sincegraduation from medical school, he hasbeen actively engaged in endocrine re­search and has made basic contributionsto a better understanding of the functionsof the mammary gland, the pituitary,adrenal, thyroid, ovary, placenta. He hasdeveloped a simple method for quantita­tive determination of pregnanediol inhuman urine. He has isolated and identi­fied 1-5-vinyl-2-thiooxazolidone, a natu­rally occurring goitrogenic compound. Re­cently he has prepared by simple methodsan adrenocorticotropic substance over 100times as active as any previOUSly de­scribed.

From 1942 to 1950 his efforts were con­centrated on experimental studies rela­tive to the chemical regulation of the rateof formation of thyroxine--an endeavorwhich led to appreciation of the potentialvalue of thiourea compounds, the suc·cessful control of hyperthyroidism in man,and the establishment of a new approachin endocrinological research.

In speaking of this contribution by Dr.Astwood, Sir Charles Harrington recentlyhad occasion to say: "A medical worlddazzled by the advent of sulfonamides,penicillin and streptomycin has not ac­corded full recognition to the brillianceof work which goes far and promises togo further toward complete success in thetherapy of hyperthyroidism."

In the opinion of the committee, itwould be an honor for this Association tomake its award this year to a man whohas brought relief to so many and who,at the age of 42 and at the height of hisproductivity, has an accomplishmentgreater than most very able men canhope for during a long lifetime.

The committee recommends that the1951 Borden Medal and prize be awardedto Dr. Edwin Bennett Astwood with thefollowing citation:

"For his numerous contributions to theunderstanding of the glands of internalsecretion;

"For his demonstration that the enzy­matic processes related to the formationof thyroxine may be interrupted by theadministration of chemical agents andthat hyperthyroidism in man can be con­trolled by nonsurgical means;

62ND ANNuAL MEETING

"For his masterly adaptation of multi­ple scientific disciplines to the solution ofclinical problems and the benefit of man­kind."

Presentation of the Borden Award wasmade by W. A. Wentworth, director ofthe Borden Company Foundation, asfollows:

"It is indeed a pleasure to be here forthe purpose of providing the means bywhich this Association gives recognitionto outstanding research in medical science.

"This is the fifth such award you havemade. Provision has been made for fivemore annual awards of this nature. Welook forward with gratification and keenanticipation to the continued constructivecooperation to the end that the satisfac­tions which come to the men and womenin our medical schools from their con­tributions to the advancement of humanhealth and welfare may be perhaps justa little greater.

"Dr. Astwood, your largest satisfaction,I know, comes from the fact that you andyour work have been selected by menwhose discernment is founded upon theirown work of a similar character and withsimilar facilities.

"The token of that selection of you bythem is the gold medal, the reverse ofwhich reads: 'Award for Outstanding Re­search in Medical Sciences,' and thissmall slip of paper the face of whichreads: '$1,000.'

"May I, on behalf of the Borden Com­pany Foundation, join with all of thosewho are present tonight in extendingcongratulations to you for the contribu­tion which you have made and the op­portunity still afforded you to make ourlives richer and healthier."

After-Dinner AddressPresident Herman B. Wells of Indiana

University delivered the after-dinner ad­dress, pointing out some of the areas inthe field of medical education whereserious problems exist.

In his address, President Wells urgedAmerican medical colleges to accept moreforeign students as a contribution to at­tainment of American foreign policy ob­jectives. Such students, he said, wouldreturn to their native countries aftertraining as America's best ambassadors.

President Wells also said that Americanmedical schools should encourage gradu­ates of foreign universities to pursue post­doctoral studies in this country, and thatmore foreign students should be acceptedfor the four-year general medical course.

9

Executive Session andBusiness Meeting

~UTES OF THE PROCEED~GS

School; Dr. F. G. Gillick, dean of Creigh­ton School of Medicine; Dr. Edward H.Hashinger, acting dean of University ofKansas; Dr. Harold Shryock, dean, andDr. Walter E. Macpherson, president ofCollege of Medical Evangelists; Dr. M.Pinson Neal, acting dean of University ofMissouri; James Pinckney Hart, chancellorand acting dean of Southwestern MedicalSchool; Dr. William R. Willard, dean ofState University of New York MedicalCenter at Syracuse; Dr. John F. Sheehan,dean of Stritch School of Medicine; Dr.John B. Truslow, dean of Medical Collegeof Virginia; Dr. A. L. Richard, dean ofUniversity of Ottawa Faculty of Medicine.

Approval of Minutes of 61 stAnnual Meeting

The minutes of the 61st annual meeting,October 23, 24 and 25, in Lake Placid,N.Y., were approved as published.

we believed were the basis for a gradUalbut nevertheless relentless loss of groundto the anti-vivisectionists.

In the years since then, those two prob­lems have been fairly well solved. Theyare not completely solved. There aresome people who believe it is the betterpart of tact and the better part of pUblicrelations to hide some of the facts aboutanimal experimentation.

However, the two big problems thatface us now are basically different. Inthe first place, we are about to enter, Ibelieve, a new kind of a controversy.

J. W. Douglas Robertson, the secretaryof the Research Defense Society in GreatBritain, spent yesterday in our officediscussing their problems and their pro­gram in Great Britain and its possibleapplication to our problem and our pro­gram in America. Dr. Robertson pointedout that anti-vivisectionists, as such, donot constitute much of a problem inGreat Britain. The big problem andchallenge in Great Britain comes from agroup of people who say: "Of course webelieve in animal experimentation, we

Work of National Soc:ietyfor Medic:al'Researc:h

RALPH ROHWEDER: It was five years agothat Dr. Carlson arrived at the Edge­water Gulf in Mississippi to report on thefirst few months of activity by the Na­tional Society for Medical Research. Atthat time, the problems of the NationalSociety for Medical Research were es­sentially two: first, research and teachinginstitutions and their leaders had aninclination to evade, to hide the factsabout animal experimentation, to main­tain a sort of "iron curtain" between theinstitutions and the public so far as in­formation on animal experimentation wasconcerned. Second, medical administra­tors met the l1factical problems of animalsupply on the basis of short-term expe­diency, usirtg any kind of method-veryoften backdoor methods-that would workfor the present.

OUr problem at that time was to re­verse those two policies, to argue asdiplomatically and forcefully as we couldto bring aboUt a change in policies, which

Roll CallRepresentatives were present from all

member institutions except the following:Medical College of Alabama, South­

western Medical School of the Universityof Texas, Dalhousie University Faculty ofMedicine, McGill University Faculty ofMedicine, Queen's University Faculty ofMedicine, University of Alberta MedicalFaculty, University of Manitoba Facultyof Medicine, University of Toronto Facul­ty of Medicine, University of the Philip­pines College of Medicine.

Introduc:tion of New DeansThe following new deans were intro­

duced by name or in person:Dr. James J. Durrett, dean of the Medi­

cal College of Alabama; Dr. James AllanCampbell, dean of Albany Medical Col­lege; Dr. F. J. Mullin, dean, and Dr. JohnJ. Sheinin, president of Chicago Medical

10

ao<.l:11::(1)

a8o

Q

ao<.l:11::(1)

a8o

Q

believe in medical progress, we believethis work should go on, but we don'tbelieve any animals should be madeavailable for experimental use."

As a result of yesterday's conferenceI feel confirmed in my suspicion thatthere is in development a movementin this country paralleling that verysubtle but insidious semi-antivivisection­ist movement in Britain. I think thename of the American organization willbe the Animal Welfare Institute. Youhave all heard about it, but you probablydid not know, that the leaders of theAnimal Welfare Institute put up themoney to get the medical research billburied last spring in New York.

The Animal Welfare Institute is pat­terned upon an organization in Britainknown as the Universities Federationfor Animal Welfare, a sort of an anti­vivisection fellow-traveler group.

We are going to have a very difficultproblem in the next few years contendingwith this much more subtle kind of op­ponent. It is not going to be a black­and white argument any more. Our ene­mies will pretend to be on our side, butthey will do various insidious thingsto see we don't accomplish the things wewant.

The other of our two new problems isvery difficult to talk about in a largegroup because it is a very touchy matter.In the last year, we have had an unusualnumber of successes. The National So­ciety of Medical Research has had a vary­ing role in the successes around thecountry. More outstanding victories havetaken place this year than in any previ­ous year. New laws have been passed ina number of states and a number ofcities, and the prospect of victory is veryclose in other places.

In the course of helping in those cam­paigns, successful as most of them were,The National Society for Medical Re­search has gotten itself in trouble forthe first time in its history in two ways.First, we have been caught between localfactions. There is another problem, how­ever. The attitude behind not telling thepublic about what you are doing andthe attitude behind solving the animalsupply problem surreptitiously now hasa new manifestation. When a positivelegislatiye .campaign is proposed in astate or a community, some of our alliesshow little faith in what I call "The PTAapproach." The "PTA," or "holy crusade"approach consists of going out and sellingideas more vigorously than anybody else.

82ND ANNUAL MEETING

You try to line up more people thananybody else, and you try to put thecause over entirely through the vitalityof your promotion.

Some of our people have the sophisti­cated notion that the better way to getthings done is to use back door, politicalmethods. I can tell you from many ob­servations, however, that such a courseis not only dangerous but ineffective inthe long run. Like paying off a black­mailer, politician trading gets progres­sively rougher and tougher. Incidentally,the whole appeal of our cause as a holycrusade-pure white against the blacksand grays of the opposition-would belost and our strength would be dissipatedif we were to stoop to back-room politicalmethods.

One of the very difficult problems of theNSMR is trying to convince our peoplethat we are political realists, that we areout to win and yet we don't believe in thekind of things that many sharp, politicaloperators and many very sophisticatedpublic relations persons on the local leveladvocate.

Progress Report-Survey ofMedical Education

DR. .JOHN DEITRICK: The 41st and lastmedical school included in the surveywas visited last May. All of you receiveda letter from the Survey Committee ex­plaining why the survey would not visitall the medical schools. The staff hasoccupied itself this summer in organizingthe materials which I believe most of youcan appreciate we brought back by thepound, and that has been fairly wellaccomplished so that we can use it forthe purpose of writing.

The staff who has worked and workedhard on this material during the summerhas been composed of some of your regu­lar members: Dr. Stockton Kimball hasgiven us a great deal of his time, as hasDr. Brown of Vermont, Fred Norwoodof the College of Medical Evangelistswho helped with the writing, Dr. Berson,whom you all know I believe, and myself.

We have taken the position that oneof our first jobs is to write down as pre­cisely as we can what a medical schoolis and does so that the first chapterswhich we have attempted to write dealtwith the activities of a medical school.Those activities as we see them are edu­cation, research and service. Having writ­ten out those chapters in rough form withthe help of the committee members who

11

ao<.l:11::(1)

a8o

Q

have spent a tremendous amount of timewith us, we have then tried to challengeourselves with what are the costs in­volved in maintaining the activity ofthese institutions?

The next chapter which we have writ­ten out is: are the sources of incomeavailable to the institutions to financethese activities? We then propose to gointo how the institutions are administered.

That, as I see it now, is the first bigdivision. When we have completed thatand rough drafts on all that material,we will get into what I call educationproper. I am not prepared to outline ourexact chapters and titles in that area yet.

As you know, we have an advisorycouncil. Men selected to serve on it rep­resented rather broad segments of publicinterest and opinion in medical education.We have presented four of our first chap­ters to them. They felt the approachclarified to them what actually went onin a medical school. They approved themethod of approach and made helpfulsuggestions to us because of the breadthof their background. We have clearedthe chapters with them and so we feelwe have polished them up so far as theirwriting is concerned and say we havethem put away, not finally, but we areprepared to move on.

Now we have your Subcommittee onPre-Professional Education, which alsohas been working hard. As the committeedeals predominantlY with the pre­professional education of the studentswhom you select to enter medical school,they have visited over 100 colleges ofeducation. They have not completed theirwork, and are continuing to visit morecolleges this year.

They plan definitely to hold a largemeeting in April where they will, I be­lieve, bring their material together andpresent it before a large conference. Weourselves are well aware of our deficien­cies, I perhaps more even than you, andwe know it is going slowly. We will notmeet the deadline of January 1. That is,we will not have the entire report written,galley-proofed and so forth by January1. That is impossible, but we realize ourobligation to you, and we hope that wewill have your report on your surveyprepared so that you may expect to haveit in your hands within the next year.We cannot give a time. We are beginningto talk about publishing and the timeinvolved, but to the best of our abilityit certainly will be in your hands nextyear~ We cannot give you a definite date.

12

I can't tell you how much the staff ap­preciates what you men and your facultieshave done. Unless you had been with usit would be almost impossible to havepredicted the lack of difficulty on personalcontact. I was frightened when I startedthis. I thought we would deal with menwho would know so much more aboutthis that it would bore them to tears ifyou went around and bothered them.That was not true, and I would think oneof the greatest compliments to medicaleducation that can be made is that overthe country, in the 41 schools we visited,the interest and the willingness to helpwent for 99.44 per cent of your faculties.

Work of the Federationof Licensure Boards

WALTER E. VEST: It is a great pleasureto report for that great old man of Ameri­can medicine, Dr. Walter Bierring. He gaveme no instructions as to what to say andhe didn't give me too much notice.

I thought I would tell you a little bitabout the workings of the Federation ofLicensure Boards, its functions and a fewof the problems. The first thing that Ihave gotten out of it as a member hasbeen the exchange of ideas, relativelyleugthy and I won't go into that, I willsay that personally I have gotten as muchout of that feature of it as anything else.

A second function of the federation isto integrate, and as far as possible withthe various state statutes, to make uni­form licensure procedures, requirementsand practices. That is especially truewhen you come to reciprocity. A statelicensing board is that arm of the stategovernment which is the buffer betweengood medical service and the populaceof the state. It is the only legal bodythat can, on the part of the state, decidewho is to be given franchise to practicemedicine and who is to be declined. Inother words, it is a dragnet to drag out,or to weed out, or to eliminate undesira­bles and those who are not deemed edu­cationally equivalent to proper practice.

Another function of that board, as Ifound it, is to keep the incoming mem­bers of the state boards informed andeducate them in the problems confrontingthe licensure of physicians.

As I see it, medical licensure is. a defi­nite science in- itself. You have to studya lot of things and know a lot of thingsbefore you are a satisfactory member ofthe state board.

When you come down to the discussion

~UTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

of the problems confronting medical edu­cation and medical licensure in the fede­ration for the next meeting which Dr.Donald Anderson has told you will beheld in February in Chicago, one of thechief topics for discussion is going tobe internships and residencies and theequitable distribution of them, if we canhave such a thing is equitable distribu­tion.

I am not so sure you can satisfy allthe hospitals on the question of internsand residencies, but one of the things thatis going to be discussed is whether it iswise, now that the senior year approachesmore nearly the internship than ever be­fore in medical education, to do awaywith the term intern, and give the menwho are now interns the term of juniorresident, and then have an intermedialand senior residency as well. That is com­ing up for discussion at the next meeting.

Another function and another thing thatwe have to face in the Federation ofLicensure Boards is the public relationsproblem of medical licensure. Every nowand then-in Virginia recently-you havea hullabaloo about some man who was notallowed to take the examination. It wentthrough the court and all that, and wefeel that better public relations should bemaintained between licensing boards andthe public generally.

I think there is one other function yougentlemen ought to know about. We whoare on the other side of the firing lineof medicine know that most of the menwho graduate nowadays are not wellversed in how to integrate themselvesinto the community. When he gets readyto practice medicine, it is rare to see ayoung man who knows what he oughtto do to get himself adjusted legally inhis community and begin the practiceof medicine. It is so much so that whenwe license a man we give him a littletalk on what has to be done to makehimself entirely legally situated in hiscommunity.

Another problem that we have dis­cussed and which we still have to discussis, of course, the foreign graduate. Onefector of that is the Americans who can­not get into the American schools and goabroad, and that problem is going to beincreased in my judgment. What are wegoing to do with the men when they getback? Several of the states have clausesin their licensing laws that limit licensesto men who are graduates of schoolsrecognized by the American Medical As-

62m> ANNUAL MEETING

sociation and schools in America-theschools represented by the example heretoday.

Then there is the problem of displacedphysicians to be discussed in the Federa­tion of Licensing Boards. It has beendiscussed in the past, and it still comesin for more discussion.

Finally, the problem that must be metby the Federation of Licensing Boards,the medical profession generally, andcertainly you gentlemen, is what we aregoing to do with the osteopaths. Theview on the osteopath varies from stateto state, and the osteopath has got to gowith the homeopath and be integratedinto regular medicine.

Work of the Council on MedicalEducation and Hospitals

DONALD G. ANDERSON: The programand activities of the Council on MedicalEdu'cation and Hospitals of the AmericanMedical Association are so familiar toall of you that I shall not attempt to re­view them. Dr. Bachmeyer spoke yester­day of the value of the liaison committeebetween the Executive Council of the col­lege Association, and the Council on Med­ical Education and Hospitals. I wouldlike to state that the council has felt thatthis committee has been a most importantand successful instrument for coordi­r-ating the activities of our two groupsfor the overall benefit of medical educa­tion.

The committee meets formally at leastthree times a year, and informally muchmore frequently. Every one of thesemeetings proves to be helpful and im­portant in making it possible for us todeal more effectively with both our majorand minor mutual problems.

We look forward eagerly to a continua­tion in the saine trend over the nextmany years of that committee and thecourse that has been followed duringthe past 10 years since it was first estab­lished.

There is, perhaps, one phase of ourprogram that has not yet become verywidely known and I might comment onit briefly. In the internship and resi­dency number of the Journal of theAmerican Medical Association, we re­ported the appointment of an AdvisoryCommittee on Internships comprised ofthe following men: Dr. Victor Johnson,chairman; Dr. S. Howard Armstrong; Dr.Granville Bennett; Dr. Ulrich Bryner;

13

ao<.l:11::(1)

a8o

Q

Dr. John Leonard; Dr. John McK. Mit­chtll1; Dr. John Paine; Dr. John Roma­no; Dr. Anthony J. Rourke; Dr. JohnB. Youmans; Dr. Robert Willson, andDr. Vernon Lippard. The purpose of thiscommittee is to study and to find, ifpossible, the place of the internship inmedical education today and as far asit is possible to do so, to look forward,certainly to the next 10 or 20 years, andtry to predict what the place of theinternship in medical education will be.

The second major function of thecommittee is to study and make recom­mendations as to what the internshipshould consist of and how it should beconducted.

Finally, we hope the committee willinvestigate any other problems relatedto the internship that seem importantor interesting to them. We had the firstmeeting of the committee last month, anda preview of the scope and program wasmade. It is too early to tell you whenthe committee will have its report andrecommendations. I imagine it will beat least a year, and possibly longer.

Since the committee at this first meet­ing did demonstrate an interest in theperennial problem of the disparity be­tween the number of interns and thenumber of internships, I believe thecouncil will postpone implementation ofthe quota plan announced last summeruntil this committee has completed itsstudy and made whatever recommenda­tions it may decide to make with respectto that problem.

A Comparative Study of Essayand Objective Examinationsfor Medical Students

JOHN T. COWLES and JOHN P. HUBBARD:

The National Board of Medical Examin­ers, with the aid of a grant from theJohn and Mary R. Markle Foundation, isdeveloping improved written examina­tions. In view of the increasingly wideusage of the national board examina­tions, which are given both during andat the end of medical training, the resultsof this study comparing objective andessay tests are of interest to all whoeducate or evaluate medical students.

This comparative study of the existingessay-type written tests of the NationalBoard of Medical Examiners and newerobjective-type tests in the same subjectshas been carried out in cooperation withthe Educational Testing Service. In an

14

earlier paper* there has been discussedthe evident advantages of the newerobjective test techniques which led tothe initiation of this project to determineempirically whether the introduction ofobjective tests might result in a significantimprovement in the national board'sexaminations. Because of its close rela­tionship to the medical schools, both inthe construction and the administrationof its examinations, the national boardhas been keenly aware of its responsi­bility for producing the best examina­tions possible.

In cooperating with the National Boardof Medical Examiners, the EducationalTesting Service has drawn from its ex­tensive technical experience not only inpreparing, administering and analyzingtest material in specialized fields but also,more importantly, in the design of newquestion types of proven superiority overthe traditional factual or true-false ob­jective tests of the classroom. The na­tional board has maintained full andabsolute responsibility for the scope, con­tent and even the wording of the objectiveexamination material as it has been ac­customed to do in the past for the essayexamination questions. The John andMary R. Markle Foundation has made agenerous grant which has made this andlater studies possible, and for which wewish to express our grateful appreciation.

Before coming to a final decision as tothe advisability of changing the nationalboard's written examinations from eS!¥lyto the objective, multiple-choice type,it was deemed best to try out the objec­tive examination in only two subjects,one in a basic science of the first twoyears of medical school and the otherin one of the clinical subjects ordinarilygiven in the junior or senior year. Ac­cordingly, last spring a part of the regu­larly scheduled examin:ltions in pharma­cology and int~rnal medicine was theobjective form and part of the sameexaminations was of the customary essaytype. The essay portion was allotted twohours and the objective portion one anda half hours of the total time providedfor each of these two subjects.

The essay questions were prepared inthe usual manner by the national board'schief examiners in the subjects concerned:

• Hubbard, J. P.: Consideration of NewerTechniques for the National Board Examina­tions. Proc. 47th Ann. Congo on Med. Edu. andLie., from Medical Education in the UnitedStates and Canada. Chicago: Council on MedicalEducation and Hospitals. 1951. pp. SO-53.

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

aBoQ

Dr. Currier McEwen in medicine and Dr.Eugene Geiling in pharmacology. Forthe preparation of the objective questions,the same two chief examiners each ap­pointed from his spbject field a commit­tee of outstanding leaders to serve underhis chairmanship in this new work. Eachof these two committees met first inPrinceton with test development 'staff ofthe Educational Testing Service to decideupon scope of the new tests and besttypes of questions; then, in accordancewith specific assignments, each committeemember drafted a set of objective testitems.

In general, the selected item typesemphasized, wherever possible, the ap­plication of fundamental facts or princi­ples in practical medical situations ratherthan mere recollection or recognition ofisolated facts. Many of these objectivequestions penetrated deeply into a widevariety of aspects of a single symptomor syndrome. Case histories, for example,were generously used in the internalmedicine examination, and interpretiveor applicatory questions were based onthose cases. In the pharmacology exami­nation, item types included quantitative orqualitative comparisons of conditions andeffects, and classification of drugs andtheir action, as well as questions of essen­tial basic knowledge. All questions wereput into mUltiple-choice form to reducethe chance element and facilitate uni­form scoring methods.

As might be expected, the committeemembers found it exceedingly exactingwork to devise sound objective test itemsas compared with the writing of essayquestions in the same field. To insureagainst ambiguous, irrelevant or other­wise weak items, each committee memberstudied and criticized the work of theother, and finally the committee met asecond time to formulate the final exami­nation.. Thus the objective test questionsdo not represent the opinion of anyoneperson or any particular locality, butrather the composite work of a com­mittee of experts from several schoolsfrom different parts of the country.

Approximately 1360 students took thecombined medicine examination in April1951, and about 1900 took the combinedpharmacology examination in June 1951.Of the candidates who took the ,combinedexamination in medicine, there were 697from schools which require national boardexaminations. This number constituteda special study group for which statisticalcomparisons were planned among the fol-

62ND ANNUAL MEETING

lowing three measures: (a) the gradeson the essay portion of the examination,(b) the scores on the objective portionof the examination, and (c) the standingof the individual students in internalmedicine as reported by their respectiveschools. For the latter rating, the schoolswere requested merely to indicate whichstudents were in the top 20 per cent andin the bottom 20 per cent of the class inrespect to proficiency in internal medi­cine. The confidential ratings of 636 stu­dents were generously provided by theirmedical schools prior to the nationalboard examinations. The following co­efficients of correlation were then ob­tained on that group:

CORRELATIONS AMONG MEDICINE TESTSAND SCHOOL RATINGS

CorreletionVeriebles Coefficient of

Essey end objective tesL .22

Essey test end school retings(high, middle, low) 21

Objective test end school retings(high, middle, low) _ 37

These correlations indicate that thereis a significant but low positive relation­ship between essay test scores and objec­tive test scores, and between essay testscores and the school ratings. The objec­tive test scores, however, correlate signifi­cantly better with the ratings than do theessay test scores.* When the middle groupis excluded, it is even more apparent thatthe objective test does a better job of dis­criminating between high and low rank­ing students as rated by their schools;with this reduced criterion group of topand bottom fifths only, the essay test cor­relates .31 with school ratings and theobjective test .53 with school ratings.

The superiority of the objective test indiscriminating the high and low groupSalso was seen in the relatively smalleroverlap of the objective test score distri­butions for high and low rated groupsthan occurred in the distributions of essaygrades for those two groups. In short,the objective test scores correspond muchmore closely with the long-term evalua­tion of students in internal medicine bytheir instructors than do the essay testgrades.

It was not possible to make a statisticalestimate of the reliability of the essay

·Uslng the Cochran-HotelUng t-test for dif­ference between correlated r's, this differenceIs significant at the 1 per cent leveL

15

ao<.l:1

grades; that is, an estimate of the accur- _acy of measurement or of stability of theindividual grades if the same studentsshould take the essay tests again. Theobjective test, however, did lend itself tosuch an appraisal. It was found that theobjective test, even though it was onlyhalf as long in time as the customary fuIl­length essay examinations, had satisfac­tory reliability, comparing more thanfavorably with reliability estimates ob­tained from other essay tests.·

Other characteristics of the. objectivetest scores such as total distribution,range, variance, influence of speed andlevel of difficulty were quite satisfactoryfor this initial objective test." Individualtest items now have been subjected torather complete statistical analysis to de­termine their difficulty, discriminationand other characteristics. These itemanalyses will serve as a guide for prep­aration of any future forms or revisionsof an objective test in internal medicine.

A similar analysis of the results of thecombined examination in pharmacologywas carried out. Of the total number ofstudents who took this examination, 546were from schools which require the ex­amination. Again this number, afterproficiency ratings by their pharmacologyinstructors, constituted a special studygroup for which statistical comparisonswere made among the same measures asin the case of the medicine examination.The coefficients of correlation based onthis special group of 546 are as follows:

CORRELATIONS AMONG PHARMACOLOGYTESTS AND SCHOOL RATINGS

Coefficient ofVariables Correlation

Essay test and objective tesL.............................•23

Essay test and school ratings (high, middle,low) •.._._.._._ _ _ _ _._...........•18

Objective test and school ratings (high, middle.low) _ _ _ _.................................•49

"Estimates of reliablllty by Kuder-Richardsonformula 20 for each of the three. 9O-minutecomparable forms of the objective medicinetest were 1'=.75••79. and .81 respectively, basedon three different groups of 370 exammees.

""Evidence of the unspeeded nature of theobjective test is the fact that over 97 percent of the examinees completed it; the dis­tribution of per cents of examinees answeringeach item correcUy indicated that the initialforms may have been somewhat too easy forthe groups tested. More than half of the ex­aminees earned raw scores of at least 75 outof a possible 100 points. The mean correlationof each objective item with total test scorewas .37.

16

Again, as for the medicine test, It wasobserved that the correlation of objectivetest scores and school ratings was signi­ficantly greater than either of the correla­tions involving essay test grades.t If tlieschool ratings may be accepted as a suit­able criterion, it may then be said thatthese objective tests in medicine andpharmaeology are more valid measures ofstudent proficiency than the essay testsin those subjects.

As in the case of the objective medicineexamination, the objective pharmacologyexamination was put through its statisti­cal paces in order to determine its relia­bility, difficulty, the influence of speed,range and variance of scores and so on.ttSimilarly, each test question was subjectedto thorough statistical evaluatioIJ- to de­termine difficulty, consistency and otherattributes of importance in consideringwhether it should be retained for futureuse, revised or discarded. The pharma­cology objective test proved to have highreliability, but like the medicine test, wasperhaps too easy for the group tested. Thiscan be adjusted in later examinations byappropriate choice of items of higherdifficulty, Objective tests easily lendthemselves to this process of recurrentrevision and improvement.

The next step was to combine equitablythe grades from the essay and the objec­tive part of each examination to arrive ata final grade for each student. From thecorrelations cited above, optimal weightswere determined for combining the twoportions of the examination into a singlecomposite grade. After applying theseweights, the combined scores thus ob­tained were converted to a grade scalecorresponding to the percentage gradescustomarily used by the national boardwhereby any grade below 75 per cent isconsidered a failure, 75 per cent andabove is considered passing, and 88 percent and above denotes honors.

In order to make these conversions con­sistent with past national board grades, acompilation was made of all grades as­signed in medicine during the preceding

f When the correlations were limited to thehigh and low rated groups only: essay test andschool ratings. r =.28; objective test and schoolratings. r = .68.

ft Estimated reliability (KUder-Richardson)was .84. .84 and .86 respectively for the three,go-minute objective pharmacology tests, eachbased on 370 examinees. Over 97 per cent ofthe examinees completed the test. About halfof the examinees earned raw scores of at least125 out of a possible 171 points. The mean cor­relation of each objective item with total scorewas .30.

]drNUTES OF THE PROCEED~GS

ao<.l:11::(1)

a8o

Q

six years. For this period the averagenumber of failures in med(cine was 11per cent and the average number of honorgrades was 10 per cent. During the sameperiod the corresponding averages forpharmacology were about 17 per centfailures and 15 per cent honor grades.Therefore, in establishing the criticalpoints of the final scale, the percentagesderived from the six-year averages wereclosely maintained.· At each stage inthese decisions as to appropriate weightsfor the objective and essay tests, and suit­able proportions of honor and failinggrades, the Examination Committee ofthe national board has been brought intoconsultation. ;

In view of the satisfactory results ofthese initial studies, the National Boardof Medical Examiners has considered itadvisable to undertake the conversion ofother subjects. Accordingly, three moreworking committees have been appointedand have met, and work has begun on thepreparation of objective examinations inpathology, pediatrics, and public healthand preventive medicine. These exam­inations, which will be ready for admin­istration in April and June 1952, will becompletely of the objective type and alsowill be subjected to thorough and criticalanalysis.

In conclusion, it may be said that theNational Board of Medical Examiners,together with the Educational TestingService and with the generous help of theMarkle Foundation, are well launched ina study of the value of objective, mul­tiple-choice examinations for the testingof medical students during and after theirmedical school training. Preliminary re­sults from this study indicate certain sig­nificant advantages of these newer testingmethods. Conspicuous among these ad­vantages, the following two are outstand­ing: (1) the objective examination, whencarefully and diligently prepared, appearsto offer more reliable and valid evaluationof the student's knowledge and his abilityto apply that knowledge to the situationat hand than can be obtained from thetime-honored essay examination; (2) the

·It may be of interest to note that the appro­priate scores on the objective test. in terms ofper cent correct answers at Which the honorand fallings points would have been Bet if therehad been no essay test scores to combine. wouldhave been approximately: pharmacology, 80per cent correct answers for honor. 65 per centcorrect answers for fail; medicine. 82 per centcorrect answers for hon9r, 63 per cent correctanswers for falL These cutoffs would haveyielded very close to the six-year proportionsof honor arid fall grades for each subject.

62ND ANNUAL MEETING

objective examination lends itself to thor­ough statistical analysis so that it may beaccurately and intensively assessed, lead­ing to recurrent revisions permittingsteady improvement of these examina­tions.

Recent Advances in PhysicalMedicine and Rehabilitation in theUnited States

EARL C. ELKINS: With the establish­ment of an American Board of PhysicalMedicine and Rehabilitation in 1947, andwith the inauguration of a regular Sectionon Physical Medicine and Rehabilitationin the American Medical Association in1950, this new medical discipline hasachieved full stature.

As the specialty is now practiced, notonly are physical agents employed for thedefinitive treatment of various diseases,but methods of rehabilitation of conval­escent and seriously disabled persons alsoare utilized. The physiatrist now hasmade a place for himself as one of theteam of medical collaborators in theproperly organized teaching hospital andmedical school. Physical medicine andrehabilitation has become a major pro­fessional service in the Army and Vet­erans Administration hospitals as well asin many civilian hospitals. It seemslogical, therefore, for medical educatorsto organize adequate programs of teachingfor undergraduate medical students, grad­uate medical students and ancillary per­sonnel such as physical therapists andoccupational therapists.

Already at least 45 of the 72 medicalschools provide some instruction in thesubject. Thirty-eight report that theyhave departments of physical medicineand rehabilitation and 33 schools statethat they have already appointed one ormore qualified specialists (physiatrists)to their faculties. Likewise, 20 additionalschools, which now do not have fullyorganized programs of teaching, have ex­pressed an interest in the establishmentof such programs. There are 87 approvedresidencies in physical medicine and re­habilitation available at 43 different hos­pitals annually.

At present there are 31 approvedschools of physical therapy and 24 ap­proved schools of occupational therapy.In addition, 15 medical schools are con­templating the establishment of newschools of physical therapy and 14 school'!are considering new schools of occupa­tional therapy. Only 11 medical schools

17

ao<.l:1

do not appear to be particularly inter­ested in developing adequate teachingprograms in physical medicine and re­habilitation, and it is to be hoped thatwith further study, these schools willbecome interested.

Because of the importance of the spec­ialty in time of national emergency, it hasbeen recommended that approximately 50additional hours of the undergraduatecurriculum be devoted to the teaching ofphysical medicine and rehabilitation.Ideally, such teaching should be devel­oped by the organization of a separatedepartment of physical medicine and re­habilitation in the teaching hospital. Fur­thermore, this department should be di­rected by a qualified physiatrist whoshould provide the integrated didacticlectures and clinical instruction necessary.This new specialty has now reached adegree of importance in solving the medi­cal problems now existing in our troubledworld which renders it advisable formedical schools to make extraordinaryefforts toward establishment of adequateprograms of instruction in the subject.

Because there is an urgent need forgreater advancement and facilities forteaching, the Advisory Committee onEducation of the Council on PhysicalMedicine and Rehabilitation and thecouncil, with assistance from others atA.M.A. headquarters, are attempting togather information which will point outthe need and which may be of assistanceto the medical educator.

A report of some of the findinils hasbeen compiled and mimeographed and isobtainable. Further studies are being madeto gather material which may be perti­nent to the problem of organization offacilities. These will be pUblished as soonas they can be compiled.

- Report of the NationalInterassociation Committeeon Internships

F. :r. MULLIN, chairman: The presentmatching plan with the definite order ofmatching student choice and hospitalchoice was first presented in the Journalof the Association Of American MedicalColleges in November of 1950. It previ­ously had been discussed and approvedin meetings of the Internships and Resi­dencies Committee of the Association ofAmerican Medical Colleges.

A National Interassociation Committeeon Internships group, under the sponsor­ship of the Committee on Internships and

18

Residencies ef the Association of Amer­ican Medical Colleges, met for the firsttime shortly after this. After consider­able exploration, it selected from amongalternatives the order of matching whicheveryone felt would give the greatestbenefit to all students in attaining thebest internships open to them, while atthe same time being fair to the hospitals.It was felt in the committee that the onlyjustification for the plan at all was theincreased opportunity offered to all stu­dents alike on a national basis tq obtain abetter internship than generally had beentrue under the previous systems. Thecommittee felt that no plan could succeedunless it had the full cooperation andcontinued support of both students andhospitals.

In the issue of April 28, 1951, of theJournal of the American Medical Asso­ciation, and in the May, 1951, volume ofHospitals, journal of the American Hos­pital Association, the plan also was pre­sented and the order of matching given.

At a meeting on May 23, 1951, the pre­vious National Interassociation Committeeon Internships, on the basis of-an analysisof a trial run last year and after consid­erations of the dissatisfaction of the oldermethod of notification, decided that theplan was desirable and that it justifiedthe recommendation of its use for thepresent year.

In view of the mounting unrest amongthE' hospitals using the old cooperativeplan, it was felt imperative to offer thisplan immediately. On :rune 8, 1951, afull report of the trial run of the match­ing plan was sent to all deans and allhospital administrators. Again the sameorder of matching was given. At thattime the deans and hospital administratorswere asked for suggestions and commentsconcerning the report of the proposedplan and the recommended actions. Bothgroups had been asked for suggestions atthe time the trial run was undertaken.It was only a couple of weeks ago thatextensive criticisms and suggestions wereforthcoming.

Following the :rune 8 meeting, theAmerican Hospital Association member­ship and the deans of the medical schoolsof this country voted overwhelminglyfor the adoption of the plan as the officialmethod of internship appointment thisyear. In the A.A.M.C. group the only threewho voted against the plan promised fullcooperation if it were adopted by themajority. The plan also was endorsedand supported completely by the Council

]4rNUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

on Medical Education and Hospitals.As a result of the support of these

groups, joined later by the Catholic Hos­pital Association, American ProtestantHospital Association and the federal serv­ices concerned with internship, a newNational Interassociation Committee onInternships was established late in July1951. This committee of representativesfrom all these groups was set up withpower to act on procedural matters re-'lating to internship appointment. Thecommittee is responsible to the consti­tuent bodies of the American HospitalAssociation, Council on Medical Educa­tion and Hospitals of the American Medi­cal Association and Association of Ameri­can Medical Colleges for approval onpolicy matters.

The committee then set about thetask of arranging the plan for this year,first calling upon the hospitals to join.They were asked to give information tothe committee for inclusion in the direc­tory to be made available to all thestudents. This official directory lists theparticipating hospitals and the intern­ships they have to offer. The hospitalswere asked to go into this cooperativeventure on the assumption that therewould be full student participation.

The committee has not always hadsmooth sailing in its effort to implementthe plan despite the fact that many deansand students have given their full sup­port to this venture and already haveagreed to participate without reservation.Some of you may not know that evenafter the plan had been officially adopted,some hospitals were definitely opposed

• to the plan and sent telegrams and othercommunications to many other hospitalsurging them not to participate in theplan.

Through the efforts of the officers ofthe American Hospital Association, par­ticularly Dr. Edwin Crosby, president­elect, and George Bugbee, secretary, thehospitals finally agreed to the plan in avery substantial number, so that at thepresent time there are only 15 hospitalsin the country which have not signedagreements to participate in the plan.The statesmanship of these men in work­ing to implement the previous commit­ment of their group is an example of thegenuine effort that many people have putinto this attempt to help the students getfull educational value out of their intern­ship year. This is the first time there everhas been an actual signed agreement onthe part of the individual hospitals to

62ND ANNUAL MEETING'

cooperate with the medical schools andthe students in the internship appoint­ment procedure. This is especially sig­nificant for the educational opportunitiesavailable in the internship year.

The National Interassociation Com­mittee on Internships, in its desire to allowas great an opportunity as possible forthe students to study and understand theproposals put to them, has extended thedeadline for student participation to thelast reasonable moment. The committeehas before it a plan, already approvedby the executive group, for student par­ticipation on the committee. It was notpossible to manage for such student par­ticipation in the time available for theinitiation of this plan last summer.

The overwhelming majority of ap­proved hospitals have accepted this planin good faith and on the assumption thatthere would be full student participation.If we are unable to secure such studentparticipation and cooperation, then it isonly fair that we notify the cooperatinghospitals immediately and release themfrom their obligation to be bound to thismethod of intern placement. It shouldbe clearly understood that the failure ofany substantial proportion of the studentsto participate means the collapse of ourcooperative efforts to bring improvementinto the method of selection of interns.In fairness to those hospitals and othercooperative groups, including deans andstudents, who have made every effort tomake this cooperative venture work, theymust know at once if there is to be anychange. We must be sure that thosehospitals which are not cooperating orthose which are willing to go back ontheir agreements may not be given undueadvantage through our delay in the un­regulated scramble for interns and intern­ships which is certain to follow abandon­ment or serious defection from the presentcooperative efforts of the various groupsconcerned with internships. As a con­sequence of the decision of this Associa­tion last summer to participate officiallyin the matching plan, we have the respon­sibility of explaining the plan thoroughlyto our students. We are bound to makeevery effort in securing the degree ofstudent participation necessary to keepfaith with the hospitals and students whohave already agreed to cooperate in thisplan designed to epable all the studentsof the country to obtain the best intern­ships open to them, accordimr to theirexpressed preference consistent with hos­pital evaluation and with fairness to all.

19

ao<.l:11::(1)

a8o

Q

Since the matching plan must, by itsvery nature, be a closed system, we haveasked the hospitals to promise to limitinternship appointments to participantsmatched with them through the plan untilafter the notification of such selections.The hospitals in the matching plan haveagreed to make no appointments or offersof appointment to seniors applying fortheir first year internships listed in theofficial directory until after the resultsof the matching plan are available. Par­enthetically, I would like to add that itwould be hypocritical of us as deans,therefore, openly to invite the hospitalsto violate their agreement by sendingcredentials and letters of recommenda­tion to participating hospitals for non­participating students until after the an­nouncement of the results of the matching.We certainly cannot expect others to beany more honest or to live up to the re­sponsibilities of commitments to anygreater degree than we ourselves arewilling to do.

Now is the time for wise educationalleadership. It is necessary that the stu­dents realize the significance of their ac­tions and have confidence in the judgmentof their teachers as expressed in the over­whelming vote of the deans last summerto adopt this plan. This decision was rein­forced in the unanimous vote of the As­sociation yesterday afternoon instructingour delegates to secure consideration bythe National Interassociation Committeeon Internships of the desirability and thefeasibility of recent proposals by somestudents to shift the emphasis in favor ofthe hospital rather than the student in thematching procedures. Such study has al­ready been promised for the committee,and we are now awaiting a detailed state­ment of the Boston plan which we areassured will be available in a few days.The previous communications about thisplan sent out by the Harvard studentshave not been sUfficiently specific to al­low for careful study and analysis of itsfull implications. It may well be possibleto incorporate such suggestions for im­provements as may be made if they arefound feasible after full stUdy.

Dr. Youmans' motion, unanimously ac­cepted by this group yesterday, also con­tained the proposition that the Associationof American Medical Colleges would beprepared to back up whatever action theNational Interassociation Committee onInternships should determine as neces­sary to preserve order and fairness in themethod of intern appointment. This

20

means that every one of us has, by thisvote as well as by the earlier one, agreedto back completely the matching plan asit now exists or as it may be modified bythe committee at its forthcoming meeting.I am certain that the members of theNational Interassociation Committee will,with reasonableness and integrity, live upto this responsibility and faith imposedin them. We are all working toward thesame end, and the wholehearted coopera­tion and firm belief in the integrity of allis necessary to achieve this goal.

The National Fundfor Medical Education

CHASE MELLEN JR: Here is a shortpamphlet entitled "A Solution for theFinancial Crisis Confronting the MedicalSchools." It contains an up to the minutereport on the progress made by the fundbesides an appeal to corporations to joinwith those that have already contributedso generously. Mr. Colt mailed it yester­day to some 400 large and leading com­panies throughout the nation.

Please slip a copy in your pocket andplease be good enough to read it whenyou have a few spare minutes. To permitme to conform to the precepts on brevity,may I ask that you accept the pamphletas my report to this meeting.

By so doing, I shall have the time inwhich to make an additional commentregarding the fund.

On the first page of the little greenpamphlet you will find Article I of theBy-Laws. The first objective stated there­in reads as follows: The interpretation ojthe needs of medical education to theAmerican public. This is vital and iswhere the Association of American Medi­cal Colleges can help materially. Dr.Deitrick's report is anxiously awaited inthis connection.

Most Americans are generous and re­sponsive to causes of national necessityand need. It is essential, however, to letthem know the whys and wherefores­also the extent of the need.

We in the fund find that, generallyspeaking, our people are not aware ofthe urgent need of medical education fornew sources of financial support. Theyknow little of your struggles to maintainhigh teaching standards and to recruita sUfficient number of qualified men andwomen to enter the medical teachingranks. Since these needs are an intimatepart of your daily lives, it seems obviousthat you are the ones best qualified to tell

MINUTES OF THE PROCEEDINGS

ao<-l:1

the facts of life to Mr. and Mrs. JohnQ. Public.

Therefore, in conclusion and with adesire to be constructive, I shall makejust one suggestion. In following it youcan, I believe, materially help the fundtrustees in gaining ever widening sup­port for the fund; support that will bringrelief to your hard-pressed medicalschools. The suggestion is that you makeevery effort and that you grasp .everyopportunity to make the needs of themedical schools a matter of commonpublic knowledge. Please don't treatthem as a confidence between doctor andpatient.

I further suggest that, like Joshua, youraise your trumpet high and blow it loudand clear. By so doing I am confidentthat all public apathy or corporationresistance to your pressing financial needswill crumble as did the walls of Jericho.

The Student AmericanMedical Association

RUSSELL F. STAUDACHER: Dr. Hinsey, inhis introduction, indicated that I keepthe wolf from the door by working asthe executive secretary for two newmedical organizations, the American Med­ic~l Education Foundation and S.A.M.A.This morning, however, I shall don thecap of the Student American MedicalAssociation and confine my remarks to achronicling of the short but progressivehistory of this organization.

A national student medical organiza­tion is not something new; it's only newin the United States. In fact, medicalstudents in -this country, by organizinglast December, became the last group ofAmerican professional students to do so.Prior to this the Student AmericanPharmaceutical Association had academicsocieties in practically every school ofpharmacy. Student dental societies arequite common in our dental schools, whilelaw students have participated in JuniorAmerican Bar Association activities foryears.

The Canadian Association of MedicalStudents and Interns boasts 100 per centschool participation and a membership of95 per cent of all Canadian medical stu­dents. The British Medical Student As­sociation has been organized for manyyears, and has made significant contribu­tions to the students and the Britishmedical profession. Similar student med­ical associations also exist in Austria,Denmark, Germany, Italy, Switzerland,

82ND ANNUAL MEETING

Netherlands, Norway, Sweden, Franceand India.

In view of these facts, it is perhaps alittle surprising that the doctors of tomor­row, in this greatest country in the world,have been without a representative na­tional organization until only a few shortmonths ago. However, despite this latestart, the Student :American MedicalAssociation today gives every promise ofbecoming one of the more importantorganizations in the medical field andthe sort of group which can-and will­reflect credit upon itself and the profes­sion it will soon represent.

Thanks to the cooperation of the medi­cal profession, the deans of the medicalschools and the medical students them­selves, this fledgling organization todayhas 41 academic societies in as manymedical schools and more than 8,000members. The prospects for adding atleast a score or more new chapters by thetime of the first annual session of theHouse of Delegates this December 27-28are very good. Should this become reali­ty, it will go far toward establishing theorganization as one of sufficient statureand standing to warrant its being invitedto present the views of the students inproblems related to medical student wel­fare and medical education. With thecontinued good help and cooperation ofyou, who are their leaders, the studentsmay expect to reach their goal.

Another signal achievement of thefirst 10 months of S.A.M.A.'s maturationhas been the adoption of a set of objec­tives to guide the group in its forwardprogress. In their deliberations, thecouncilors labored long and hard tofashion a forward-looking flexible pro­gram. These objectives were decidedupon after many conferences. Many ofthe objectives are such that they cancome to immediate fruition; others arelong-range and will take years to ac­complish. The members of S.A.M.A.humbly commend their program to youfor your appreciation and studied com­ments.

The third milestone in organizationalsuccess of the Student American MedicalAssociation is the forthcoming Journal ofthe Student American Medical Associa­tion. In January 1952, all of the nation's26,000 medical students-not just S.A.M.A.members-will receive their first issueof a new 72-page monthly publicationdesigned primarily for the medical stu-dent and intern. .

In this journal will be found all those

21

ao<.l:1

features and writings which tend to makea medical student fully cognizant of theresponsibilities which lie ahead in thepractice of medicine.

The editorial division in this new pub­lication equally divides the contents be­tween the scientific papers of student,intern and physician, and the writings ofauthorities in the fields of the practicaland business side of medicine.

By decision of the council, politics andcontroversy will find no room in thejournal. In its stead, the editors plan togive the student of medicine exactly whathe wants, whether it is sharing the ex­periences of medicine as a science or asa livelihood. The new journal will belongto its readers 100 per cent.

In conclusion, I should like to make anappeal for your cooperation in the estab­lishment and support of a constituentsociety in each of the recognized medicalschools in the country.

We have experienced labor pains and,following them, the pains which accom­pany growing up, but I am confident thatwith your cooperation and the good helpof your offices, the Student AmericanMedical Association can make a significantcontribution to medical students, medicaleducation, the medical profession and thegeneral public in the years which lieahead.

Report of the Chairman of theExecutive Council

JOSEPH C. HINsEY: Actions taken atExecutive Council meeting held October24, 1950, in Lake Placid, N.Y.:

A new Committee on the Journal ofMEDICAL EDUCATION was named consistingof Lowell T. Coggeshall, chairman; JamesFaulkner; Robert A. Moore.

The name of the Committee on Pre­paredness for War was changed to thePlanning Committee for National Emer­gency. Its membership was named asfollows: Stockton Kimball, chairman;George Packer Berry; John Z. Bowers;Melvin A. Casberg; Edward L. Turner.

The name of the Committee on Socialand Environmental Medicine was changedto the Committee on Environmental Medi­cine. Its membership was named as fol­lows: Duncan W. Clark, chairman; JeanA. Curran; Harry F. Dowling; WilliamW. Frye; David Rutstein; Leo Simmons;Ernest Stebbins.

The name of the Committee on Stu­dents from Abroad was changed to Com­mittee on Foreign Students. Its member-

22

ship was named as follows: Francis ScottSmyth, chairman; Maxwell E. Lapham;C. N. H. Long; Harry A. Pierson; AuraE. Severinghaus; Edward L. Turner;Francis A. Young.

An ad hoc committee to explore thepossibility of organizing teaching insti­tutes under the direction of the Associa­tion was appointed. It consisted of Dr.Arthur C. Bachmeyer, chairman; Dean F.Smiley; John Stalnaker.

Announcement was made of a grantfrom the John and Mary R. MarkleFoundation, made October 18, 1950, underthe following terms:

"That, from the funds available forappropriation Ninety Thousand Dollars($90,OOO)-or as much thereof as may benecessary-be appropriated to the As­sociation of American Medical Collegesas an emergency grant, payable on orbefore December 31, 1952." No publicitywill be given this announcement untildefinite projects under it are undertaken.

The following resolution initiated bythe round table on "Specific InternshipRequirements for Licensure-Yes or No"was submitted to the Committee on In­ternships and Residencies: ''Resolved thatthe Association of American MedicalColleges is opposed to the principle ofrestrictive internship requirements as aprerequisite to state licensure, and ap­proves the appointment of a committeeto study this problem in cooperation withthe Federation of State Medical Boardsof the United States of America."

It was voted that John Stalnaker benamed director of studies for the Associ­ation of American Medical Colleges.

Dr. Dean F. Smiley was made editorof the Journal of MEDICAL EDUCATION ofthe Association of American MedicalColleges.

The decision was made that a manag­ing editor be employed to assist in theproduction of the Journal of MEDICALEDUCATION, this editor to be picked inconsultation with the editorial board.The decision was made to change thename of the Journal to the Journal ofMEDICAL EDUCATION.

Actions Taken at Meetings February 9-13,1951, Palmer House, Chicago:

Administrator Carl R. Gray Jr. of theVeterans Administration with Mr. Byrneand Mr. Dinsdale appeared before theCouncil. Highlights of his statement were:

(a) He sees no reason for the apprehen­sion of the medical college deans regard­ing the VA medical care program.

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

(b) Not a- single important recom­mendation made by the Department ofMedicine and Surgery has been adverselyacted upon by the administrator.

(c) The administrative organization ofthe VA is under study by a managementengineering concern in Chicago (Booz,

• Allen & Hamilton).(d) The recommendations of the Uni­

versity of Minnesota Deans Committeehave been received by the administratorand have been turned over to Booz, Allen& Hamilton.

(e) Circular #16 was developed in theeffort to make sure that the authority ofthe physicians in the VA hospitals wassufficient to guarantee overall medicalcare of a high quality.

Dr. Paul Magnuson read correspond­ence which appeared to make the follow­ing points:

(a) Circular #16, though authorizedand distributed, never became a part ofthe manual under which VA hospitaladministrators operated.

(b) The definition of the duties ofregional office managers and VA hospitalmanagers followed Circular #16 in timeand really supplanted it.

(c) Previous to October 1949 the chiefmedical director had nominated the VAhospital managers. In October 1949 thiswas made a committee function. In Oc­tober 1950 the Appointing Committee wasnamed and Dr. Magnuson was not in­cluded, though his first assistant was.

(d) Administrator Gray had promisedDr. Magnuson that he would set up abureau type of organization, the fourbureaus to be:

(1) Insurance, (2) Claims, (3) Vet­erans Rehabilitation and Education, (4)Medical. This he has never done, thoughthe solicitor general assured Dr. Magnu­son that the administrator had authorityto do so.

(e) The administrator, when asked byDr. Middleton, "Who is the surgeon gen­eral of the VA?", replied, "Under thelaw, I am."

(f) Dr. Magnuson feels that the chiefmedical director should stand betweenall VA hospitals and the administrator.At present he does not.

At the conclusion of these hearings theExecutive Council directed Dr. HughWood, chairman of the Committee onVeterans Administration-Medical SchoolRelationships, to prepare a statement.This was revised several times andadopted by the Council. It was preparedfor presentation to the Senate investigat-

62ND ANNuAL MEETING

ing committee on the VA headed bySenator Humphrey. (Copy of this hasalready been sent you.)

The following new committees wereappointed:

(a) Liaison Committee with BlueShield Medical Care Plans, D. F. Smiley,~hairman; Lowell T. Coggeshall; RichardYoung.

(b) Committee on Post-Doctoral Edu­cation, John Truslow, chairman; GeorgeN. Aagaard; Kendall Corbin; Aims C.McGuinness; Charles Wilkerson.

The Council went on record as stronglyrecommending for the present againstissuing medical college acceptances, evenprovisional ones, more than one yearprevious to matriculation. (Copy of thishas already been sent you.)

The Council went on record as recom­mending to the member colleges an 11­month year for the duration of the emer­gency but avoidance of the acceleratedthree-year program if possible. (Copy ofthis has already been sent you.)

The secretary was instructed to writeDr. Harold Diehl as a member of theHealth Resources Advisory Committee of'the National Resources Board stating thatthe Council had gone on record as favor­ing the setting up of some plan by whichselected students would be permitted todrop out of their regular medical coursefor one year to act as teaching fellows.

On Tuesday evening, February 13, theExecutive Council met with the ExecutiveCommittee of the Board of Trustees andthe Council on Medical Education andHospitals of the American Medical As­sociation. The whole matter of financialsupport of medical education was dis­cussed. No definite conclusions, however,were reached.

Actions Taken at Meeting March 18, 1951,Palmer House, Chicago:

The secretary was instructed (a) todraw up appropriate resolutions on thedeath of Dr. Fred Zapffe and to publishthem in the Journal of MEDICAL EDUCA­TION; (b) to devote a portion of the Mayissue of the Journal of MEDICAL EDUCATIONto setting forth Dr. Zapffe's contributionsto the Association and to medical educa­tion.

Dr. Hinsey reported on the hearingbefore the Senate committee investigat­ing the Veterans Administration. In hisopinion it was a very satisfactory hearingin that adequate opportunity was givento get all important past difficulties andsuggested plans for improvement into the

23

ao<.l:11::(1)

a8o

Q

Senate record. It is Dr. Hinsey's under­standing that plans are being drawn forthe reorganization of the Veterans Ad­ministration which will guarantee thatall matters concerning the 147 VeteransAdministration hospitals will channel upto the administrator through the chiefmedical director. (A report of this hearinghas already been sent to all memberinstitutions.)

The Council approved in principle astatement being prepared and distributedto the medical colleges by the Joint Com­mittee on Medical Education in Time ofNational Emergency. This statement in­cludes the following: "The Joint Com­mittee does not recommend that the med­ical schools at this time adopt an ac­celerated program."

The secretary was instructed to write aletter to Dr. Daniel Blain, medical direc­tor of the American Psychiatric Associa­tion, placing our Association on record asendorsing and offering to cooperate ina conference on graduate education inpsychiatry projected for June 1952, oneyear following the conference to be heldat Ithaca, N. Y., June 1951, on under-

.graduate education in psychiatry.

Actions Taken at Meetings May 31 BeJune 1, 1951, 185 North Wabash Avenue,Chicago:

It was voted that the Association re­establish its membership in the Ameri­can Council on Education.

A working committee was appointedto prepare a succinct statement of thegeneral objectives of undergraduate med­ical education, this statement to be re­vised by the Executive Council beforebeing distributed.

The Council voted to recommend to theAssociation that the University of OttawaFaculty of Medicine be voted into affiliatemembership in the Association with thestipulation that the school be resurveyedin two years and that its status be re­considered at that time.

Dr. Thomas Hale was named repre­sentative of the Association on the Sub­committee on Education of the AmericanMedical Association's Committee onMedico-Legal Problems.

The Medical Film Institute was re­quested to begin the preparation anddistribution of reference cards for recentmedical teaching films, these cards to becomparable to the Library of Congressreference cards for books.

The Council expressed the opinion thateach medical school will be well advised

24

to be giving serious thought (a) as to howit can best contribute to the em~rgency

medical care in case of bombing disaster,(b) as to how it would continue itsteaching program if its plant were madeinoperable as the result of bombing.

The May 23 recommendations of theInterassociation Committee on Intern­ships were approved. This involves apermanent 12-man National Interassocia­tion Committee on Internships operatinga machine-matching plan financed by acharge of $2.50 to each student and $2.50to each hospital for each internship filledthrough the plan. The individual medical

, schools are to be polled.Tentative budgets for the year begin­

ning September 1, 1951, were approvedas follows:

The Secretary's office... ....$66.425The Journal of Medical Education 35,000The CommiHee on Student

Personnel Practices 105,000Action on the Medical Film Institutebudget was deferred.

The Council was notified that the As­sociation's representative to the Pan­American Congress on Medical Educa­tion in Lima, Peru, in May was Dr. Max­well Lapham.

Approval was voted for co-sponsorshipwith the Conference of Professors ofPreventive Medicine of a conference onthe teaching of preventive medicine to beheld within the next two years. Dr.Ward Darley was named co-director.

Summary of Actions Taken at ExecutiveCouncil Meeting, October 26-27, 1951:

1. The matter of the expiring lease onthe Association headquarters space at 185N. Wabash Avenue, Chicago, was dis­cussed. Decision was made to find newspace somewhere in the Chicago area.A committee consisting of Dr. Smileyand Mr. Stalnaker was appointed to bringin recommendations to the ExecutiveCouncil at its meeting February 7-8, 1952,for the procurement of new space.

2. A schedule of visitations to ninemedical schools in cooperation with rep­resentatives of the Council on MedicalEducation and Hospitals was approved.

3. After considering the report of avisitation made October 1-5, 1951, theCouncil unanimously recommended thatat the business session of the 62nd An­nual Meeting, the Association vote theUniversity of North Dakota School ofMedicine (two-year school of the basicmedical sciences) into full membershipin the Association.

ao<.l:11::(1)

a8o

Q

4. The recommendation was made thatthe Association's 63rd Annual Meeting beheld November 10, 11, 12, 1952, at theBroadmoor Hotel in Colorado Springs.A Long Conference of Professors of Pre­ventive Medicine, of which Dr. WardDarley will be co-chairman, will takeplace_ at the same hotel the week preced­ing, November 2-8, 1952.

5. The report of Horvath & Horvath'saudit of the Association accounts Sep­tember 1, 1950, through August 31, 1951,was approved.

6. Repnrts of representatives to im­portant conferences were received andacknowledged as follows: (a) Dr. A. C.Furstenberg, 4th Annual Conference onAging; (b) Dr. Leland Parr, 9th Meet­ing of the U.S. National Commission forUNESCO; (c) Dr. Maxwell Lapham, Pan­American Congress on Medical Education.

7. Special consideration as given tothe report re the assistance bein2 ren­dered to foreign students by the Associa­tion and its Committee on ForeignStudents.

8. Reports of representatives who hadserved as consultants in the considerationof plans for the development of new med­ical colleges in Florida and New Jerseywere discussed.

9. Approval was given to the recom':mendation of the Committee on Audio­Visual Education that the name of theMedical Film Institute be changed toMedical Audio-Visual Institute effectiveFebruary 1, 1952.

10. The Council went on record as ap­proving in principle the U.S. Army'sprojected plan for establishing militaryscholarships in the various medical col-leges. •

As chairman of our Council, I havebeen deeply grateful for the way that themembers of our Association have carriedout the responsibilities of these variouscommittees, and I want to express theCouncil's deep appreciation for the co­operation and the support that we havehad.

It wouldn't have been possible to havegotten some of these things through, orall of them as a matter of fact, withoutthe teamwork of our member institutionsand their staffs. We are deeply grateful,Mr. President.

Vote of Appreciation

A vote of appreciation of the Associa­tion to Dr. Hinsey and the ExecutiveCouncil for the accomplishments of 1950­51 was unanimously passed.

62ND ANNUAL MEETING

Action Taken upon the Recommen­dation of the Executive Council

1. The University of Ottawa Facultyof Medicine was unanimously voted intoaffiliate membership in the Associationwith the stipUlation that the school beresurveyed in two years and that itsstatus be reconsidered at that time.

2. The University of North DakotaSchool of Medicine was unanimouslyvoted into full membership in the Asso­ciation as a two-year school of the basicmedical sciences.

3. The Association voted to hold its63nd Annual Meeting at the BroadmoorHotel, Colorado Springs, Colo., November10-11-12, 1952.

Report of the Secretary

DEAN F. SMILEY; This is the first yearsince 1903 that this Association has metwithout hearing a report from Dr. FredZapffe. He served the Association longand faithfully and as I become betteracquainted with the work which thehome office is called upon to do, I be~ome

more and more amazed at the multipleresponsibilities he carried alone, or atmost with the aid of two secretaries. Yougave him full cooperation throughout hislong term of office and pleased him noend when you put the stamp of approvalupon his efforts and provided for thefuture stability of the Association byvoting the $500 annual dues. We all oweFred a deep debt_ of gratitude, but I amperfectly sure that he died feeling wellsatisfied that his 50 years of service tothe Association had been well invested.

The past year has been a busy one atthe home office. The increased financialsupport provided by membership duesand foundation· grants has made possibleincreased activities. Three new commit­tees were appointed and began work.These are: the Liaison Committee withBlue Shield Medical Care Plans, theCommittee on Post-Doctoral Educationand the Committee on Veterans Admin­istration-Medical School Relationships.Nine of our 14 committees have held oneor more meetings with funds now avail­able to make such meetings possible.Half time secretarial help has been pro­vided two of our committees, the Com­mittee on Internships and Residenciesand the Committee on Foreign Students.

The statistical studies of the Associationhave been placed on a much more ac­curate basis and have been extended into

25

ao<.l:11::(1)

a8o

Q

several new areas as Mr. Stalnaker, ,ourdirector of studies, will report to you.He needs your continuing cooperation inperfonning this important function.

The Journal, with its new name andstaff of three, has made many advance­ments and is hoping to expand to amonthly publication on January 1. Itsmanaging editor, William Swanberg, willgive you more details in his report. Wehope you will keep the Journal in mind,and we solicit your articles, editorials,news items and letters to the editor.

Medical school visits and inspectionsthis past year included the medicalschools of North Carolina University,Howard University, Boston University,the University of Puerto Rico, the Uni­versity of ottawa, Creighton University,University of Iowa and the Universityof North Dakota. Visits are planned fornine schools this coming year.

Several steps forward were made dur­ing the year in the field of public informa­tion. Wide distribution was given ourcommittee's manual, "Public Understand­ing and Support of Medical Education,"and it received very favorable comment.Four thousand copies of our booklet,"Admission Requirements of AmericanMedical Colleges," were distributed, mostof them upon request. A roster of publicinfonnation officers in the medical col­leges of the country was prepared anddistributed. The second meeting of pub­lic relations officers connected with med­ical schools was held in Miami Beach inJune in conjunction with the 35th annualmeeting of the American College PublicRelations Association. Their meeting nextyear is to be in Cleveland, and a com­mittee is laying plans for a more exten­sive seminar on medical school publicrelations problems. It is hoped the planswill be completed early in the year, andall medical colleges are urged to send arepresentative to the June meeting.

Requests for assistance from foreignstudents in finding appointments for ad­vanced stUdy in this country have in­creased this past year. The functions ofour office in 43 such cases consisted in(a) providing a copy of our booklet,''Fellowships, Funds and Prizes Availablefor Graduate Medical Work in the UnitedStates and Canada"; .(b) forwarding copyof the letters to the Council on MedicalEducation and Hospitals of the AmericanMedical Association with the request thata list of internships and residencies besent the student; (c) instructing the stu­dent to submit a transcript of his records

26

to Dr. Francis Scott Smyth, chairman. ofour Committee on Foreign Students, inorder that Dr. Smyth may act as hissource of reference in this country.

The flood of questionnaires directed tomedical college deans has apparentlycontinued unabated. Of the 31 submittedto the home office this past year, 13 wereapproved and 18 disapproved.

Our home office staff has increased to19 and with the termination of ourpresent lease April 30th, 1952, we willhave to find larger quarters. We havemoved as rapidly as we could in im­proving and extending the services ren­dered. We have as yet been able to donothing beyond a little exploratory think­ing in the promising field of medicalteaching institutes. A considerable amountof effort has gone into the developmentof the Internship Matching Plan and Fac­ulty Roster, as well as the reorganizationof the Journal. Important studies in atleast two new fields are under considera­tion by our director of studies. If thereare additional services, studies or activi­ties that are urgently needed, we wouldwelcome your suggestions.

Report of the Managing EditorWILLIAM H. SWANBERG: Volume 26

carried 528 text pages and 123 advertise­ments. Eighty-five authors contributed 50original articles. There were 18 pages ofeditorials, 32 of general news, and 86pages of college news. Books reviewedtotalled 167. I think you will all agreethat this is a tremendous bargain for a$5 subscription price! There are somewho say, o£ course, that my judgment inthis matter is not as objective as it mightbe. I maintain that, among other things,Dr. Bachmeyer said substantially thesame thing in his address yesterday. Hewas simply a bit less commercial!

In March of this year, Dr. Dean Smileysucceeded to the editorship and I wasprivileged to become the Journal's firstmanaging editor.

At the 1950 Annual Meeting, the Jour­nal Committee made several recom­mendations to the Executive Couneil. Ibelieve that most of these suggestionshave been carried out. The change inthe title was the first and most importantstep toward improvement. Through thename Journal of MEDICAL EDUCATION in­stead of "Journal of the Association ofAmerican Medical Colleges," we callattention to our central purpose: the ad­vancement of medical education. In addi-

~s OF THE PROCEED~GS

ao<.l:11::(1)

a8o

Q

tion, the title has a much better eye-andinterest-appeal.

There have been several changes inthe typographical layout of the Journaland an orientation or summary statementhas been added at the beginning of eacharticle. We have carried a list of officers,staff and committees of the Association ineach of the past four issues. The Collegeand General News sections have been en­larged. The Book News section has car­ried longer and signed book reviews ofselected books.

Three new sections have made theirappearance this year. The PersonnelE~change seeks to help fill vacancieswhere they exist or to find jobs for thoseseeking them. The Audiovisual sectionprovides news and audiovisual sugges­tions, lists new film releases, providesshort reviews of films of interest to med­ical educators and gives credit and sourceinformation on these films. The sectioncalled Our Readers Write was begun inthe September issue. It is a letter-to-the­editor section and will be continued ifthere are enough worthwhile letters.

On the business side, the mailing listfor the Journal is approximately 4,500,which is about the same as a year ago.In the advertising department, a contractwas signed last January with a profes­sional advertising representative. Theagreement requires that they solicit allpossible advertisers, with the exceptionof book publishers. Thus far they havesecured no new ads, though they haveglowing promises for next year. SinceMay, we have written four sales lettersto some 30 book publishers. These havebrought in $850 in new advertising.

The third main division of the work ofthe managing editor concerns public in­formation. A public information programfor medical education means that youthink good medical education is important,that people should know this and giveit support, and that you have assignedtime and personnel to let them knowabout good medical education and itsneeds. In this category, the Journal officeanswers numerous inquiries for informa­tion and sends out press releases to thewire services, certain newspapers andperiodicals. Our main claim to news hasbeen an advance copy of the Journal,which we enclose with our press releases.We pick out articles most likely to beof interest to a wider audience and writeup a simpler version. So far, our recordhas been good. We have received news­paper or wire service coverage for some

62ND ANNUAL MEETING

article from each Journal since the Mayissue. In the field of public relations or­ganizations, the managing editor attendedthe American College Public RelationsAssociation meeting and the Adams Coun­ty Model Public Relations meeting. Themanaging editor can by no means dojustice to the Journal and to the real andextremely important requirements of thejob of a public information officer for theAssociation.

Ancillary work done by the Journaloffice includes consultation to the MedicalFilm Institute on publication problemsand, in the past two months, the handlingof publication details for their film re­views.

This ends the formal section of my re­port but I would like to take a few moreminutes to discuss the plans we have forthe Journal.

The most important recommendationthat I can make is that MEDICAL EDUCATIONbecome a monthly publication. There areseveral reasons: (1) the problems ofmedical education are important enoughto deserve monthly discussion in ourofficial Journal; (2) the news value ofthe contents is almost completely lost byissuing every other month, and (3) thereare enough original papers deserving at­tention to maintain a monthly publication.

A monthly would mean more text pagesper year and therefore more space forthe original articles section. At the sametime, the size of each issue would bereduced slightly. This would mean thatthe ratio of advertising pages to textpages would be increased. Increased ad­vertising would pay for more than half ofthe costs of becoming a monthly. If wecan increase the number of subscriptions,it will mean more advertising, higherspace rates, and eventually, a Journalthat pays its own way.

In conjunction with a monthly wewould like to develop a real selling cam­paign for this needed increase in eircula­tion and advertising. It is essential thatthe main basis for advertising solicitationbe that the Journal is paid for by thepeople who receive it.

In my opinion, our subscription sellingproblem would be simplified if the num­ber of copies received by the schoolswere reduced to 25 per school: one copyto the dean, one to the public relationsoffice, two copies to the library, and onecopy to the head of each major depart­ment. If only one Journal goes to eachdepartment head, rather than a selectedfew in each department, I think we have

27

ao<.l:1

a better chance of selling a subscriptionto the other members of the department.

Let me say at once that it is not aneasy matter to sell advertising if ourcirculation number is cut in half. Inother words, this will make our workmore difficult at first. Our long-run goal,however, is some 10 to 20,000 individualsubscribers who bUy the Journal becauseof their interest in medical education andbecause the Journal of MEDICAL EDUCA­TION is an indispensable aid to their be­coming better medical educators. It isessential that we accomplish this goal,and we will need all the help that every­one attending this meeting can give us.

Our plans for the editorial sections ofthe Journal call for a central focus onthe continuing improvement of the orig­inal articles section. This takes muchmore time and energy than people realize.

We hope to be able to devote two orthree issues each year to a comprehensivetreatment of some of the major topics inmedical education.

When we find time and/or material,two additional sections might be added.The title for one could be the TeachingClinic. This would provide, among otherthings, an opportunity to record for ourreaders short reports of teaching experi­ences, successful or unsuccessful, in speci­fic situations. Another section might beeither a bibliography, comment, or sum­mary section on articles of concern tomedical educators which have appearedin other journals.

The next two years will be the mostdifficult ones for the Journal. The wel­come aid from the Markle Foundation isproviding the funds necessary to help usthrough this period.

I wish that each of you would consideryourself an unofficial member of theJournal staff. When you have commentsor suggestions, news or good articles,please send them to us.

We are fortunate in having an excellentJournal Committee. With their help weplan to produce the kind of Journal ofMEDICAL EDUCATION that leads and servesthe best in medical education.

Report of the Director of StudiesJOHN M. STALNAKER: At the last annual

meeting, the new Executive Council ap­poitl.ted a director of studies for the Asso­ciation. This is his first report.

The Executive Council did not describethe duties for the director of studies; noreport of a person in a similar role has

28

been uncovered. The director of studiescan but hope that in this report he hasnot taken unwarranted advantage of thisfreedom or stepped outside of any un­specified boundaries which the ExecutiveCouncil or the Association assumed hewould recognize.

Actually, no effort has been made toseparate the work of the director ofstudies for the Committee on StudentPersonnel Practices from that of thesame individual acting for the Associa­tion. The central office staff of the Asso­ciation operates as a team under thefriendly guidance of Dr. Dean Smiley.

.When work needs to be done, the avail­able person does it. It has been the goodfortune of the director of studies to workclosely with the secretary in helping tokeep the office running as smoothly as ithas during these active times, and to getthe necessary work accomplished.

Some tasks, in many cases small ones,have been done by the director of studiesfor the Executive Council and for theofficers of the Association as well as forsome of the committees. Meetings havebeen attended as a representative of theAssociation, speeches given, papers pub­lished, correspondence handled and nu­merous memoranda prepared.

The report of the Committee on StudentPersonnel Practices has ouUined the oper­ations which have been the responsibilityof the director of studies. This presentreport will project operations toward -thefuture and describe some of the problemswhich require solution in the years ahead.

The central office of the Associationhas undergone marked changes duringthe past few years. Dr. Fred Zapffe de­veloped the Association and, almost singlehanded, himself did virtually everythingin the office. As is inevitable when suchan able pioneering and energetic persondrops from the scene and new hands takeover, a period of change and adjustmentfollows. In addition, the Association, Inlarge part as a result of the ground workDr. Zapffe laid, has taken on new respon­sibilities and activities appropriate to thegroup in this time of national devel­opment.

It seems, therefore, that a study of theactivities of the central office and itsmost appropriate organization, staffing andfinancing, could wisely be undertaken atthis time, and this type of study isrecommended.

Such a study, if properly done, shoulddelineate the general areas where theAssociation can, in the immediate future,

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

be especially effective. A rough blueprintfor the next few years would have manyadvantages. It can be developed only bya person familiar both with medical edu­cation and with the evolution and devel­opment of our culture. It is no small task.

While recognizing fully and acknowl­edging the many and significant con­tributions to education by organizationsof medical practitioners, the A.A.M.C.should appreciate the legal and actualdifferences which may exist or developbetween the activities of organizations ofpractitioners and of medical educators.Fortunately, the two groups are by nomeans mutually exclusive. The overlapat any period should not, however, ob­scure the desirability for the educator toremain independent and to assume activeleadership in matters of medical educa­tion, a fact stressed by Dr. Tresidder tothis Association some years aio andechoed by others. The great values ofclose cooperation and coordination of theactivities of all groups concerned withmedical education should be :r:ealized.

The A.A.M.C. could well, at this time,give serious study to the school inspec­tions and accrediting to make sure thatthe process is kept from degeneratinginto a means of forcing conformity to non­essentials rather than developing as anaid to focusing the attention on areas ofimportance for the training of futurephysicians. The Association should beable to contribute to improvements here,and it has a public responsibility to do so.

As medical education is a field in whichpublic interest is growing, and probablywill continue to grow in the next fewyears, the A.A.M.C. should gather forits own information and for public en­lightenment as much factual data aboutcertain phases of medical education aspossible, and devise means for presentingsuch information so that the public willunderstand it. Supplying statistical datacan be annoying, but the fundamentaldata, if not collected by this Association,will be estimated or derived by others.The amount of pleading and repeatedrequests required of the central staff ofA.A.M.C in the case of a few deans sug­gests that not all deans appreciate thevalue of making sound information avail­able. The medical schools, it is recog­nized, have other duties and concernsthan supplying statistics, but the deansshould appreciate that the information isbeing collected for the good of medicaleducation.

There are several obvious areas where

62Nn ANNUAL MEETING

statistical studies are now being under­taken with the cooperation of the medicalschools. The studies of applicants to themedical schools will be expanded so thatmore information will be available aboutthe number of students making repeatedapplications and, if possible, some addi­tional information about the applicants.The study of accomplishment in medicalschool and the drop-out rate should bebrought up to date, and efforts are beingmade to do so. Such information shouldbe available to the undergraduate col­leges. It is particularly important at thistime to have accurate information onattrition rate in the medical schools. Anew study on some aspects of the facultiesnow teaching in medical schools is, withthe aid of Dr. Rusk's committee, wellalong. A full report on this study will bemade at a later date.

More information probably should beobtained on the cost of medical education.A project on developing certain standard­ized accounting procedures has much tobe said for it. Obviously, all medicalschools are not the same and details ofaccounting must differ. However, certaingeneral principles might be developedapplicable to all schools. The use of somegeneral standards could result in reveal­ing information of value to all medicalschools.

The internship, like the weather, issomething that is widely talked aboutbut very little is done about it. Thisyear the matching plan for internshipappointment has been adopted after atrial run. The cooperation of the hospi­tals in this plan has been overwhelming.Dr. E. L. Crosby, president-elect of theAmerican Hospital Association, has beenextremely helpful in securing this degreeof cooperation. The A.M.A. council alsohas cooperated fully. However, withinthe narrow time limits available, the in­terassociation committee did not succeedin communicating effectively with thestudents so that they would recognize andappreciate the values of the plan forthem, and the deans apparently did notsucceed either. As a result, student op­position has developed. The plan, de­veloped for the benefit of the stUdent,cannot succeed without student coopera­tion. The plan appears to have advan­tages over previous plans. With studentand hospital support it cannot fail.

Your director of studies has been actingas the director of operations for the Na­tional Interassociation Committee on In­ternships, and has devoted a very large

29

ao~

1::(1)

a8o

Q

amount of his time to this work and aneven larger amount of his nervous energy.

There are many other possible areaswhere intensive studies might prove es­pecially fruitful at this time, especiallyareas concerning the curriculum.

The problem of securing adequate per­sonnel to design and develop these majorprojects is a greater one than securingadequate financial support. While thereis now a small staff working on studies inthe Association office, there is still a longway to go before the office will beequipped to turn out, with the desiredpromptness, the work needed.

Your director of studies, with the ap­proval of the chairman of the ExecutiveCouncil, has done his stint of governmentservice. Fortunately, his work for thegovernment and also for other outsideagencies has brought him into contactwith extensive research pertinent to hiswork in the A.A.M.C. He is serving asecond year as a member of the ScientificAdvisory Board to General Vandenberg,chief of staff of the Air Force, and as amember of the committee on the selectionof men going into the foreign service forthe Department of State, and as a con­sultant to the Navy through the Officeof Naval Research. He has also beenassociated with the research committeeof the College Entrance ExaminationBoard, attends many meetings of theEducational Testing Service and has donesome committee work for the AmericanPsychological Association. He spoke atmeetings of the American Psychological,the American Public Health, and theAmerican Medical associations, and theinvitational conference on testing prob­lems, and has attended other conferences.

The period of the last two years hasbeen one of adjustment and learning,staffing and getting basic records intoshape. The next several years shouldsee the rounding out of more publishedreports.

Report of the TreasurerJOHN B. YOUMANS: Your treasurer is

pleased to report that the financial affairsof the Association are generally satis­factory.

During the fiscal year there was a ma­terial improvement in our financial posi­tion. An excess of general income of$10,585.95 compares with a loss of $211.81for the preceding fiscal year. This amounthas been transferred to the General FundReserve, which now totals $30,321.72,

30

compared with $19,735.77 the previousyear. This strengthening of the GeneralFund Reserve provides some insurancefor an organization such as ours, whichis primarily a spending organization, butis only a minimum amount needed toinsure any degree of permanency in theactivities of the Association.

It must be pointed out that the fiscaloperations of the Association are of twodistinct kinds: general operations sup­ported by the unrestricted general incomeof the Association, and special operationssupported by special restricted funds forwhich, in effect, the Association acts astrustee. However, the general unrestrict­ed income itself has consisted partly ofgrants from outside agencies, made insupport of such activities as the pUblica­tion of the Journal of MEDICAL EDUCATION.During the past fiscal year, $62,500 ofbudgeted income was derived directlyfrom unrestricted outside grants. Regularinternal income of the Association frommembers' dues and other sources re­mained at essentially the same level. Itis clear that additional regular, unre­stricted, income will be necessary tomaintain the activities of the Associationshould other income be reduced and it isin this connection that a General FundReserve is necessary.

Budgets for the new (current) fiscalyear include $69,000 derived from unre­stricted outside grants. $52,500 transferredfrom the previous year and $143,600 ofregular income, for a total of $265,100.All budgets have been approved by theExecutive Council. Details of income andbudgets are given on the accompanyingexhibits (see page 31).

The Comparative Balance Sheet for thefiscal year 1951 shows total assets of$188,013.97 compared with $195,017.30 asof August 31, 1950, a decrease of $7,003.33which is represented by an expenditureof special, restricted funds. Investmentstotal $89,779.55 compared with $33,000the previous year, but the increase is theresult of the purchase of short-term se­curities from working capital not current­ly needed, thus securing interest incomefor the Association.

An advance of $5,000 was made to theNational Interassociation Internship Com­mittee. This will be repaid from theincome of that committee.

During the year, minor changes havebeen made in account titles to conformwith good business practices, and month­ly balance sheets have been prepared inaddition to income and expense state-

~UTES OF THE PROCEEDINGS

ending August 31, 1951, which will befiled with this report and presented inabbreviated form in the printed minutes. Irecommend that all who are interested inthe fiscal affairs of the Association readthe report and audit.

ASSOCIATION OF AMERICAN MEDICAL COLLEGESCh/c:ago, /llInols

Report on AudIt for the Flsc:al Year Ended August 31, 1951

Horwath and Horwath have examined the balance sheet of the Association ofAmerican Medical Colleges as at August 31, 1951, and the statement of incomeand expense for the fiscal year then ended, and have presented a report thereon,which consists of the exhibits and schedules and is filed in the Association office,It is summarized here:

31

96,792.90

58.20425.00258.32

$188,013.97

$ 1,303.18

$ 89,779.55

$ 98,234.42

$ 300.00

400.00

100.00200.00

TOTAL ASSETS _ .

DEFERRED INCOMEDues income 1951-1952 _._ $ 23,750.00China Medical Board Grant......................................... 50,000.00

LIabilities and Reserves

TOTAL CURRENT ASSETS. _ .

INVESTMENTSUnited States Government Bonds-Series G

Face value _ .__ $ 33,000.00United States Treasury Bills-

Cost _ __.__ 56,779.55TOTAL INVESTMENTS._ __._ .

CURRENT LIABILITIESFederal income tax withheld from employees $ 1,084.20Federal retirement tax. -............ 218.98

Travel advances _ _ _ .Cash in banks

First National Bank of ChicagoGeneral __ _ _ _._ _..__ $ 83,141.70Operating _ .__ 11,786.66

Bank of Montreal __ _ 1,864.54

Accounts receivable-employees __. .Deposit-United Air Lines __ _ .Prepaid insurance _ .. __..__.__ _.-- .

Balanc:e Sheet

AssetsCURRENT ASSETS

CashPetty cash

Chicago ._ _ _.._ _._ _ $New York __ _ .

62ND ANNuAL MEETING

ments, for control purposes. John M.Stalnaker has been authorized to signchecks in the absence of Dr. Dean F.Smiley. Details of the finances are con­tained in the report of the aUditors, Hor­wath and Horwath, for the fiscal year

ao<.l:11::(1)

a8o

Q

73,750.00

• The deficit of $211.81 of expense over income in 1949-50 was taken from reserves. Otherbalances are restricted and carried forward.

TOTAL .

TOTAL LIABILITms AND RESERVES

82,639.07

41,328.0711,193.01

3,536.653,833.32

22,748.02$93,225.02

BalanceAugust 31,

1951$12,996.30(2,410.35)

deficit

30,321.72

$188,013.97

Expenses1950·1951

$ 53,544.8528,353.78

77,975.4133,384.40

48,221.451,166.68

42,251.98$284,898.55

7,500.0036,955.58

49,901.885,000.00

35,000.00$226,842.04

RESERVES FOR RESTRICTED FUNDSMedical Film Institute _ $ 14,729.66Committee on Student Personnel Practices................ 41,328.07Survey on Medical Education _......................... 22,748.02National Inter-Association Committee on Internships 3,833.32

Committee on StudentPersonnel Practices $111,803.48

Medical Film Institute.................. 7,621.83Projects for Medical

Film Institute.............................. 1,856.22Internship Study .Survey on Medical Education...... 30,000.00

TOTAL $151,281.53

TOTAL RESERVES FOR RESTRICTEDFUNDS _ ..

GENERAL FUND RESERVEBalance August 31, 1950 $ 19,735.77

Excess of income over expensesSeptember 1, 1950 to August 31, 1951.................. 10,585.95

SUMMARY OF INCOME AND EXPENDITURES FOR THEYEAR ENDING AUGUST 31, 1951

Restricted FandsCarried Forward from New Income

August 31, 1950 1950·1951Secretary's Office............................ $ 66,541.15Journal ._......................................... 25,943.43

ao<.l:11::(1)

a8o

Q

32

BUDGET-1951·1952SECRETARY'S AND TREASURER'S OFFICE.

INCOMEDues-79 Members $500 $ 39,500.00Dues-8 AmI. Members $125.......................................................................... 1,000.00Interest on Investments.................................................................................. 825.00Overhead 15,000.00Miscellaneous Income...................................................................................... 100.00Special Grants _................................................................................... 21,470.00

$ 77,895.00

EXPENSESSalaries and Annuities _ ,.$ 20,000.00

~TES OF THE PROCEEDINGS

• Ali revised by Executive Council-February 1952.

JOURNAL OF MEDICAL EDUCATION·

33

9,000.0010,000.001,000.00

12,000.00500.00

3,000.001,800.002,000.004,125.00

14,470.00

13,479.20161.18

2,863.1110,000.005,000.00

15,000.0011,824.58

Rent and House Expenses _ _ _ .Supplies, Postage, Telephone and Telegraph, Etc .Furniture and Equipment. _ .Travel _ _ .Administrative Expense .Annual Meeting................................................................•...............................Committee on Internships and Residencies .Medical Film Institute _ .Contingency _ .Journal Subscriptions for Members .

$116;328.07

EXPENSESSalaries and Annuities _._ $ 40,000.00Supplies, Postage, Telephone and Telegraph, Etc..................................... 4,000.00Furniture and Equipment.. _......................... 2,000.00Travel _ - -.................................... 4,000.00Contracted Service and/or Machines _ _ _ _................ 8,000.00Markle Grants

a-Interest Measures .b-Records Work. _ _ _ - .c-Brosin Project - .

Special Studies .Faculty Register .

Overhead to Association. _ - .Contingency , - .

$116,328.07

INCOMERevenue from Testing _ _ _._ _ $ 75,000.00Special Grants-Previous year _ _ _...... 16,503.49Balance from Previous year _ _............................................. 24,824.58

COMMITTEE ON STUDENT PERSONNEL PRACTICES

EXPENSESSalaries _ _ _ $ 11,770.00Printing and Mailing __ _...... 16,750.00Travel. _ _............ 1,000.00Circulation Promotion.................................................................................... 2,880.00Advertising Promotion __ 1,600.00Furniture and Equipment _ _ __._..... 1,000.00

$ 35,000.01)

INCOMEAdvertising _ _ $ 10,000.00Subscriptions and Sales _ _ _ _.............. 3,000.00Special Grant _ _ _._ _._ _ _................ 7,530.00Subscriptions to Members (from dues) _........................ 14,470.00

$ 77,895.00

$ 35,000.00

62ND ANNUAL MEETING

ao<.l:11::(1)

a8o

Q

ao<.l:11::(1)

a8o

Q

34

MEDICAL AUDIO-VISUAL 'INSTITUTEINCOME

Special GrantsChina Medical Board. $25.000.00Sloan Foundation _............................................................................. 15.000.00Association of American Medical Colleges................................................ 2.000.00

Projects and Earned IncomeGeorgia State Dept. of Health (Maternity)............................................ 3.000.00Geo. Washington University (Birth of a Family) __.._ __ 500.00Dept. of State (SCC-la-1156)...................................................................... 1.000.00Office of Naval Research (N9-onr-93501) _ _..... 462.71U. S. P. H. 5.-HTS-5020 _ _.... 718.00Film Distribution _................. 500.00

Transfer from Previous year _ _ _ _..__.. 11.193.01

$59.373.72

EXPENSESSalaries $41.560.00Rent and House Expenses _........................................................... 2.500.00Supplies. Postage. Telephone and Telegraph. Etc..................................... 3.500.00Furniture and EquipmenL. _.._..__ ._ _ _.._._.... 1.000.00TraveL.._ _ _ _. __._ ..__ 3.800.00Contracted Services and/or Machines.__ _ .__ 2.500.00Annual Meeting and Others _.._._ _ _._ _ _._.... 1.000.00Publications. Reprints. Special Mailing.__ _ _......... 1.000.00Contingency _ _ _ _ _............................. 2.513.72

$59.373.72

MINuTEs OF THE PROCEEDINGS

Accomplishments and Recommendationsof Committees

ao<.l:11::(1)

a8o

Q

Committee on Audiovisual AidsWALTER A. BLOEDORN, chairman: The

committee's activities of the past yearhave consisted largely of the furtheranceof the program of the Medical Film Insti­tute of the Association of American Medi­cal Colleges. The committee has metthree times: November, April and Sep­tember, and twice with the AdvisoryCommittee, which incorporates the com­mittee, in November and April. Distinct'progress has been achieved toward de­velopment of the many types of Instituteservice to medical aUdiovisual education.

Financial SUPPOTt: Financial support ofthe Institute is based on the concept ofthe financing of universities and themedical schools themselves: that a largeproportion of self - support will derivefrom services rendered, but that the needfor complete self-support should not existlest it be permitted to endanger the in­tegrity of the program. The Common­wealth Fund, the John and Mary R.Markle Foundation and the Alfred P.Sloan Foundation have continued theirbasic support into this third year of op­erations. The Association has added itslimited support. There have been Insti­tute earnings. Grants and contracts haveadded to the Institute assets.

AdministTation and OTganization: Theorganizational goal of the Institute is afirm program well integrated with theoverall Association objectives in medicaleducation. There have been importantorganizational and administrative im­provements in the operation of the Insti­tute. Integration with the secretary'soffice has progressed directly with theexpansion and reorganization of that of­fice. The revivification of the Journal ofMEDICAL EDUCATION has opened new chan­nels of continuous and predictable publi­cation for Institute information.

PeTsonnel: It is conceived that the workof the Institute can best be accomplishedby a small but skilled staff, with theassistance of expert consultants on callfor special needs. Dr. David S. Ruhe andDr. Adolf Nichtenhauser comprised thebasic professional staff. Dr. John L.Meyer II completed his training fellow­ship July 1, 1951, to be succeeded by Dr.Floyd C. Cornelison Jr. as fellow in train-

62ND ANNUAL MEETING

ing. Mr. George C. Stoney, talented docu­mentary film worker, has 'joined the staffas specialist in production consultation.In film reviewing activities Mrs. Marie L.Coleman, Dr. Marvin Weinberg, Dr. Nor­man Lenson, Dr. Louis Bergmann, Dr.Louis Girard, Dr. Benjamin Lewis andmany other specialist part-time reviewershave been working with the Institutestaff. Bernard V. Dryer and Dr. V. F.Bazilauskas have continued as principalspecial consultants.

InfoTmation and Cataloging: The in­formation services of the Institute arebeing developed to provide a variety ofmaterials coverfng the most importantaspects of audiovisual planning, produc­tion and utilization:

1. A motion picture card index service,nonqualitative in substance and modifiedfrom cards of the Library of Congress,has been launched under a cooperativearrangement with the Committee onMedical Motion Pictures of the AmericanMedical Association and the' Committeeon Medical Motion Picture Films of theAmerican College of Surgeons.

2. A second edition of "Medical Teach­ing Motion Pictures Now in Production"has been issued in revised form; a thirdedition is soon to be released.

3. Evaluative cataloging has proceededunder the initiating general grant of theRockefeller Foundation and under a cate­gorical grant from the National Cancer!nstitute to review fiIms in neoplasticdiseases. A paper, "The Critical Cata­loging of Medical Films," was publishedas a supplement to the Journal of MEDI­CAL EDUCATION, Vol. 26, No.3. Sixteen"Reviews of Films in Atomic Medicine"have been published by Health Publica­tions Institute for national distribution.Ten "Reviews of Films in Psychiatry,Psychology and Mental Health" have beengiven limited distribution, along with 11"Reviews of Medical and Related Films."Nineteen preliminary reviews of films in"Social and Environmental Factors ofMedicine," with report, have been givenlimited circulation. Fifty miscellaneousreviews are in process of publication anddistribution. Thirty-nine reviews of filmsin neoplastic diseases have been com­pleted and published. A categorical eval-

35

ao<.l:11::(1)

a8oQ

uative study of the films ill the cardio­vascular diseases was begun September 1under a grant from the National HeartInstitute. Short condensations of reviewshave been initiated in the Septemberissue of The Journal of MEDICAL EDUCA­TION. Medical schools have been suppliedexpert panels at Rochester, Syracuse, Al­bany, Boston and New York City.

It must be emphasized that each Insti­tute review is a detailed and serious studyof the film in question; a mine of informa­tion for producer and serious user alike.

4. New notes concerning audiovisualpersonnel and events have begun in theJournal.

5. Numerous letters and calls of inquiryhave been serviced.

6. A special study was conducted on"Television and Medical Education," andpUblished in The Journal of MEDICALEDUCATION, July 1951, Vol. 26, No.4, pp.245-259. .

Consultation and Liaison Services:From its beginning the Institute was ex­pected to be available for all requests forassistance, from the whole field of medi­cal education. As the result, the Insti­tute's staff and consultants have beencalled upon frequently and intensivelyfor a wide variety of services to manyorganizations and individuals concernedwith professional audiovisual education:

1. Medical schools. The Medical FilmInstitute worked with the Joint Commit­tee for Medical Education in Time ofNational Emergency and with that com­mittee's Sub-Committee on Curriculum.The Institute represented the Associationin behalf of medical educational interestsbefore the Federal Communication Com­mission at the March hearings on educa­tional television. General audiovisual­television surveys were conducted atGeorge Washington University and atWestern Reserve University. A result ofthe latter survey was the establishmentof an AV-TV laboratory. Assistance wasgiven to Dr. V. F. Bazilauskas in his AV­TV survey of the State University ofNew York at New York City. Consulta­tion on films in prospect or productionwas given to Duke University (Dr.Markee and Dr. Brown), the Universityof Maryland (Dr. Krantz), The GeorgeWashington University (Drs. Parks andMcLendon, vide infra), and New YorkMedical College (Dr. Granirer). Servicesof varied kinds were offered to JeffersonMedical College, Cornell University, Co­lumbia, Temple, Pennsylvania, Universityof Buffalo, Washington University (Mo.),

36

and the Medical College of Israel.2. Assistance was given in a variety of

ways to the following organizations orgroups: Medicine, American Academy ofPediatrics, Association of American Anat­omists, Academy of Ophthalmology andOtolaryngology, New York County Medi­cal Society, New York State Medical So­ciety, Massachusetts Medical Society,U. S. Public Health Service in several ofits divisions, American Public Health As­sociation, International Scientific FilmAssociation, New York State Departmentof Health, deans of the VeterinaryMedical Schools, American Colleges ofPharmacy, American Association for theAdvancement of Science, medical repre­sentatives of the governments of Indo­nesia, Nationalist China, Jugoslavia, theClay-Adams Company, the Charles PfizerCompany, United World Films, the Na­tional Broadcasting Company (Telepro­grams, Inc., vide infra), and the UnitedNations. Many individuals representingvaried medical and health interests weregiven advice and assistance to the limit ofpresent Institute resources.

Curriculum Integrational Services: As­sistance in the curriculum integration ofaudiovisual aids is at the stage of ex­ploration and evaluation of the availableaudiovisual materials. or initial imple­mentation of existing plans. The fields ofactivity continue to be primarily preven­tive medicine and public health. neo­plastic diseases, cardiovascular diseasesand psychiatry. Opportunity to workwith the Western Reserve Universityproject of curriculum reexamination andrebuilding has been afforded by the ap­pointment of Bernard V. Dryer as direc­tor of the new AV-TV laboratory, whosestUdies are geared into the overall pro­gram of that school. Perhaps no moreeffective chance exists to study the possi­bilities for saturation of the medical cur­riculum with audiovisual materials, andto create new patterns and concepts ofutilization.

Experimental Production: The work ofthe Institute in the production of newaudiovisual materials has been based onthree concepts: (1) that actual creativeexperience is necessary to maintain andstrengthen the consultational skills of theInstitute staff for use by the medicalschools and other medical agencies; (2)that selected production is necessary tovalidate presently held ideas about visualeducational tools in medicine and there­fore should be undertaken with the hopeof providing models for emulation, and •

MINUTES OF THE PROCEEDINGS

III

l.

ao<.l:1

(3) that scientific personnel who will bemost valuable to medical education in thefuture must have a real and continuingproductional experience. The Institutehas therefore continued to undertake afew production projects in line with theseconcepts.

The two-government film on the prog­ress of cancer research: "Challenge: Sci­ence Against Cancer," has been re-editedto a 20-minute version, "The Fight ­Science Against Cancer," and a 10-minutenewsreel version, "Outlaw Within." Ateaching filmstrip has been completed.The book, "The Challenge of Cancer,"has received wide circulation. Manyhonors have been given this film package:"Challenge'" received first prize in thescientific division of the InternationalFilm Festival at Venice and the AssociatedScreenwriters script award; "The Fight"was runnerup for the short subject Oscarof the Motion Picture Academy; the bookreceived the Westinghouse Sciencewritersaward for text and was placed ~ong the50 best books of the year for its typog­raphy.

"The Embryology of Human Behavior,"a motion picture made in conjunctionwith the Office of Naval Research andthe Bureau of Medicine and Surgery ofthe U. S. Navy, was completed a yearago, but continues to be tested in actualutilization for possible revision and forreexamination of the process of its pro­duction and pre-release audience testing.A book, "Infant Development" (SUb­title: "The Embryology of Behavior inPictorial Outline"), has b~en published byHarper's as a reference volume to be usedwith the film. The film was recently ac­cepted for showing at the medical sectionof the Edinburgh Film Festival.

A new motion picture, "A Concept ofMaternal and Neonatal Care," was pro­duced in conjunction with George Wash­ington University School of Medicine. Itoffered additional experience in the proc­esses of medical film production and pre­release audience testing. The film wascompleted in August 1951. A fact sheetto amplify the film contents is in prep­aration.

Assistance in special aspects of produc­tion was given to the National Broadcast­ing Company's "American Inventory"experimental television program in adulteducation supported by the Alfred P.Sloan Foundation. Two programs ofmedical subject matter were providedwith research and script: "Panic andMorale in Civil Defense," July 22, and

62ND ANNUAL MEETING

"The Costs of Medical Education" (work.ing title) for October 28.

Ccnsultational and script assistance wasgiven to the U. S. Public Health Serviceand Film Documents for a film report or.the hospital facilities program tentativelyentitled "The Community Hospital."

Distribution: The goal of effective dis­tribution is to have good audiovisual ma­terials easily available to teachers andstudents when they need them. The roleof the Institute at this time is conceivedto be a contributory one: to discover howbest to achieve this result for the medicalcolleges and to implement those findings.

The Institute has been assisting in theestablishment of two medical professionalfilm libraries serving geographical regions.In conjunction with the Medical Societyand the Department of Health of theState of New York, the Institute has aidedmaterially in appraisal and cataloging ofan initial stock of films handled by theOffice of Health Education in Albany. InBoston the Massachusetts Medical Societyand the Postgraduate Medical Survey,which include the medical schools of thatcity, have begun preliminary film ap­praisals leading to the establishment of asimilar regional film library based on theexperience of the former.

The Institute has been engaged in apilot experiment in the reproduction andsale of unusually good medical teachingfilms not generally available, or only atprohibitive costs.

Contributions to the distribution abroadof good American medical films have beeneffected through recommendations to theU. S. Department of State for the Inter­national Motion Picture Division, and bycontact with the purchasing missions ofseveral foreign governments.

Utilization: The chief purpose of theInstitute in the field of utilization ofaudiovisual aids is to assist the medicalteaching profession in developing the dis­ciplines of the several visual languages,and to further the supply of adequateequipment to carry out those disciplines.The Institute has assisted in developingan audiovisual study room in conjunctionwith the library of the New York MedicalCollege to explore the problems and solu­tions of making audiovisual materialsavailable to medical students for out-of­class study.

With the Washington University Schoolof Medicine, the University of MissouriSchool of Medicine and the New YorkMedical College, preliminary trials werebegun with utilization of motion pictures

37

ao<.l:11::(1)

a8oQ

for the teaching of social and environ­mental factors of medicine.

Training: The Institute staff believesthat the demand of the medical collegesfor acceptable audiovisual tools presup­poses talented medical scientists trainedintensively in the media of mass com­munication and devoted to the purposesof medical instruction. To this end, allfunctions of the Institute are partly de­signed to discover, train and provideexperience and positions for such talentedpersons. Men skilled in medicine, educa­tion and audiovisual media will transformthe present chaos of medical audiovisualeducation into an orderly and creativeplan of use of the splendid modern mediaof human communication.

A full-time working fellowship hasbeen devised, comprising formal univer­sity schooling, reading, film analysis andstudy, and limited practical experience.The fellowships are in evolution as theInstitute expands. Dr. John L. Meyer IIhas completed the first fellowship. Dr.Floyd C. Cornelison Jr. has begun asecond.

Reviewers in the film evaluation pro­gram have been given informal trainingin film pathology. The expert reviewpanel personnel also have gained newinsight into the anatomy and pathologyof the present teaching films.

The staff, through its real experiencein consultation and production, haslearned a great deal. With lengtheningexperience, the Audiovisual Committeeand Advisory Committee have becomemore progressively informed of the prob­lems that are inherent in developing au,.diovisual tools in medicine.

Summary: Within each area of its broadsix-point program of work toward theimprovement of medical audiovisual aids,the Medical Film Institute has made im­portant advances. The program has wid­ened, the personnel base has strengthened,the prestige of the organization hasgained ground, the contributions to medi­cal education have been noteworthy andwell worth what they have cost.

AcceptanceThe annual report of the Committee on

Audiovisual Education was accepted with­out revision at the Business Meeting,Tuesday, October 30.

RecommendationsThe Association approved the following

recommendations of the Committee onAudiovisual Education:

1. That the name of the Medical Film

38

Institute be changed to the Medical Au­dio-Visual. Institute.

2. That the program for publication begiven impetus in order that the MedicalAudio-Visual Institute be of increasingservice to the medical schools.

3. That the program of consultation ofthe Institute be expanded with direct

-service of increasing volume to the medi­cal schools.

4. That experimentation be carried outin the distribution of three to five films­designed for medical school instruction.

5. That the Institute continue to trainpersonnel in the techniques of audiovisualeducation.

CommiHee on EnvironmentalMedicine

DUNCAN W. CLARK, chairman: I. ORI­GIN AND BACKGROUND OF THE AS­SOCIATION'S ACTIVITY IN ENVIRON­MENTAL MEDICINE:

Amel4can medical colleges, both indi­vidually and collectively through theirAssociation, have long recognized thesignificance and values of medico-socialteaching. So far as organized activity inthis regard is concerned, the Association'sCommission on Medical Education in 1932affirmed the importance of social andenvironmental factors and of the need topermeate teaching in the clinical coursewith the concept of medicine as a socialagency.

At the 1938 meeting of the Association,a symposium on "Home Visits by MedicalStudents as a Teaching Asset" was themain feature of the program. The pointreferred to repeatedly by most of thespeakers was that home visiting was adevice that provided students an oppor­tunity for studying the patient as a whole.Experience with domiciliary medical careteaching programs were presented as wereenvironmental and clinical-public healthcase studies. Common to all these pro­grams was opportunity for observation ofthe physical, social, economic, occupation­al and recreational environment of thepatient. Not in all instances was this theprimary purpose of such instruction. Insome the intent was primarily the con­duct of a program that readily simulatedthe conditions of general practice for thevalue this had in the total education ofthe student.

In 1941 the Association set up a specialsubcommittee responsible to the Commit­tee on the Teaching of Public Health andPreventive Medicine and charged it with

MINUTES OF THE PROCEEDINGS

I/'

ao<.l:11::(1)

a8o

Q

the obligation of exploring the subject ofmedico-social teaching. At the next meet­ing, the chairman, Dr. J. A. Curran, LongIsland College of Medicine, reported theresult of a questionnaire survey conductedamong the member schools, after whichthe committee was established as an in­dependent body and invited to continueits study.

In 1943 agreement on collaboration wasestablished with the American Associa­tion of Medical Social Workers and Elea­nor Cockerill, University of Pittsburgh,was appointed co-chairman of the jointcommittee" with Dr. Curran continuingas chairman representing the A.A.M.C.

In 1944 a Project Committee, under thechairmanship of Dr. Jonathan E. Rhoads,University of Pennsylvania, was formedand given power to formulate policiesand plans for the conduct of a Study ofthe Teaching of the Social and Environ­mental Factors in Medicine. After select­ed trial studies to determine the practi­cability of their methods, approval for amore intensive study was obtained fromthe parent organizations and a grant insupport of the work came from the Mil­bank Memorial Fund. Harriett M. Bart­lett, Massachusetts General Hospital, wasappointed executive secretary for theperiod of the study in 1945 and 1946.Twenty medical school teachers and 12social workers took part in the projectstudy.

The general aims of the study were:(1) to gather information on the present­day teaching of the social and environ­mental aspects of medicine, (2) to analyzethe data obtained, (3) to evaluate themethods and techniques of instruction inuse, and (4) to offer recommendationsbased on conclusions drawn from thestudy.

In the course of the study, informationconcerning 65 schools was obtained bycorrespondence and 13 schools were vis­ited directly by a study team. The finalreport of the joint committee appearedin a monograph, published in 1948 byThe Commonwealth Fund, entitled, "Wid­ening Horizons in Medical Education."This valuable report has had a wide dis­tribution and, apparently, an importantinfluence on medical education.

With completion of the assignment ofthe joint committee, Dr. Curran resignedas chairman and a reconstituted Commit­tee on Social and Environmental Medicinewas formed. Its name was shortened tothe Committee on Environmental Medi­cine in 1950.

62ND ANNUAL MEETING

II. COMMITTEE ACTIVITY FOR1950-51:

Functions: The present Committee onEnvironmental Medicine conceives itsprincipal function to be the conduct ofstudies on certain aspects of present-dayteaching in social and environmentalmedicine. In the natural course of suchactivity, the committee will:

(1) Exchange information with relatedprofessional groups similarly engaged instUdies of this field, so setting up a twoway information and consultative servicebetween such groups and the Association.

(2) Attempt identification and inter­pretation of trends in research in socialand environmental medicine for the rela­tion these may have to the expandingcurricular content of this field.

(3) Attempt identification and inter­pretation of trends in programs and formsof medical care for the significance thesemay have to such teaching.

(4) Prepare critiques with respect tothe problems and accomplishments ofmedical schools in the teaching of socialand environmental medicine togetherwith recommendations thought to be ap­propriate to its scope of activity.

Meetings: Meetings of the committeewere held in Chicago on February 13, andin New York City on September 21, 1951.Much of the work of the committee was,of course, handled by correspondence. Itwas beyond the capacity of the commit­tee to engage itself simultaneously in allof the activities listed above, and theyare listed to suggest the possible rangeof the committee's function.

Specific Study Projects Considered:(1) A comparison of those administra­

tive arrangements in medical schoolswhich most easily permit the conduct ofinstruction in environmental medicine.

(2) A study of the more recent andnewer methods employed in the teachingof social and environmental medicine.

(3) Consideration of a conference ofthose most active in the field of socialand environmental medicine. (Specialfunds would have to be sought for thisproject. It appeared somewhat unneces­sary at that time in view of the proposed1952 Conference of Professors of Preven­tive Medicine.)

(4) A survey identifying those schoolsconducting inter-disciplinary studies wherethere is collaboration of representativesfrom the social sciences (other than socialwork and clinical psychology) with thoseengaged in medical teaching.

(5) The collection of information on

39

aor.P

activities of related groups for the pur­pose of calling attention to their work asa service to the administrators of medicalschools.

(6) An evaluation of audiovisual aidsused in this field.

(7) Postgraduate instruction in socialand environmental medicine.

(8) Consideration of the methods in­volved as well as the instructional con­tent of personal health education by thephysician.

Decision was made to work on projectsNo.1 and No.5 above.

Study of Administrative Arrangementsin Medical Schools which Most EasilyPermit the Conduct of Instruction in En­vironmental Medicine: A letter datedMay 7, 1951, was sent the dean of eachmedical school for the purpose of ac­quainting him with the proposed programof the committee, and to seek his wish inthe matter of whether he or one of hisassociates would cooperate with us inproviding the information needed. Theassumption was that in many instancesit would be his preference to designatethe member of the faculty most active inthis field of education as his representa­tive in dealing with the committee. Forthe bearing this method may have, if any,on the problem of securing informationby correspondence and to give a roughindex as to assignment of important ifnot primary responsibility for activity inthis field, it is of interest to report thatreplies were prepared in 13 instances bythe deans and in 10 by their administra­tive associates. Representing the deansin the remaining replies were 29 profes­sors of preventive medicine, five intern­ists, five psychiatrists, one pediatricianand one bacteriologist. In nine othercases deans designated four professors ofpreventive medicine, three internists andtwo psychiatrists from whom replies hadnot been obtained at the time of submis­sion of this report.

On June 20 a letter was sent to thedean or his representative inquiring aboutthe settings in which the teaching of so­cial and environmental medicine is con­ducted. The information sought is out­lined in the following excerpt taken fromthe letter:

"Our committee is interested in ob­taining information about the administra­tive arrangements and settings in whichthe teaching of social and environmentalmedicine is conducted in medical schoolstoday.

"Such teaching usually has as its ob-

40

jective the general purpose of havingstudents understand the significance ofsocial and environmental influences intheir case studies for the value this mayhave in patient care and, further, thatthrough this and other educational ex­perience they may grasp the concept thathealth and disease are dynamic expres­sions of the relations of man to his en­vironment. These objectives, directly orindirectly, can be said to concern alldepartments of a medical school.

"The strong feeling exists that the de­gree to which these objectives are real­ized is considerably less than that thoughtdesirable.

"It is assumed that one reason for thispartial failure resides in the difficulty ofbringing the student into a position wherehe may observe the patient in the latter'snatural environment, particularly thehome.

"The purpose of this inquiry is tocollect information about the variety ofadministrative arrangements, particularlythose of recent innovation, which mayfavor achievement of the objectives listedabove.

"By 'administrative arrangements' ismeant those adaptations of programs ofmedical care which, for reasons of medi­cal service, or to fill a teaching need, orin the conduct of a research project aidby creating a situation in which the stu­dent has a maximum of direct access toknowledge about the patient's environ­ment. Direct knowledge of environmentimplies entree of the student to the nat­ural environment of the home and pref­erably contact with the family. Intro­duction of the student to a patient's homemay derive from an extension of medicalservices (e.g. home care programs; com­prehensive medical care for home, hospi­talized and ambulant prepaid insurancesubscribers; group practice arrangements,etc.), or it may come from special ar­rangements in teaching or research.

"It is our assumption that the varietyof administrative arrangements, the ex­perience with them, the identity ofschools trying experimental programs, thepossible adaptability of some of thesearrangements to the situations of othermedical schools-that such informationmay be useful to the administrators andfaculties of medical schools. There maybe obtained as well a cross section of someof the current practices in medico-socialteaching and a suggestion of recent trends.

"Consequently, it will be very muchappreciated if the following types of in-

]drNUTES OF THE PROCEEDINGS

ao<.l:11::(1)

aBo

Q

formation could be placed at the disposalof this committee:

"Description of those administrativearrangements at your college which aidin the teaching of social and environ­mental medicine.

"Identification of these as havingtheir origin primarily in programs ofmedical care, or teaching, or research.

"Description of the role and degreeof participation of the student in suchprograms, particularly in the study offamilies.

"The role of departments of preven­tive medicine and public health in suchinstruction."Analysis of Replies: The replies re­

ceived were in most cases reduced toreasonably common and uniform terms,but it was decided not to report in thisfashion since, in the act of paraphrasing,too many errors were likely and a fair orfull picture of each school's programwould not be possible.

Some schools will be mentioned to il­lustrate certain forms of educational ac­tivity. It should be made clear that suchreference does not imply that this is theprincipal medium of their approach tothe subject under discussion. The pur­pose of the report is to unfold the patternand directions education in this field istaking.

No conclusions will be drawn since thisis a preliminary report and those schoolswhich have not responded as yet maywish to do so. A final report also shoulddiscuss the possible relationships of cer­tain observable trends.

By reason of the particular questionselected for inquiry-student participa­tion in medical care in the home as adevice for learning social and environ­mental medicine-there is in most in­stances necessarily implied a case-proj­ect type of approach. There are otherswho doubt the wisdom of this in favorof teaching as a routine_ and regular prac­tice the integration of social and environ­mental information in the total study ofeach patient in the hospital setting, wherethe student is most easily supervised.This practice is, or should be, the ultimateobjective of all clinical teaching. Theargument against home visiting is wellexpressed in the following comment fromone of the schools:

"The department of medicine for manyyears has emphasized the significance ofconsidering the patient as a whole. Thishas been taught to the clinical clerks onthe wards as they take histories, with

62ND ANNUAL MEETING

special exercises on psychosomatic medi­cine under psychiatric supervision. Thestudents (and interns) are expected to gointo the social and environmental factorsin considerable and appropriate detail.It is not necessary at the undergraduatelevel to visit the actual homes of thepatient to learn objective physical situa­tions. The patient's description is ade­quate. The heart of the problem is thepatient's reaction to his environment. Thisis obtained by carefully supervised his­tory taking, both by internist and psy­chiatrist. The students are expected totalk with such friends and relatives whoserelationship to the patient may seem im­portant.

"When it is necessary to make physicalrearrangements of the patient's life, it isimportant to understand modern methodsof physiological appraisal, and the avail­able time should be spent in learningthem rather than visiting the patient toclimb stairs that could be described inhighly quantitative terms by some mem­ber of the family or, indeed, the patienthimself.

"To help with the emotional setting, itwould be more constructive to talk overthe patient's conflicts with an instructorwho understanrls something of the dy­namics of the emotions than to take atwo-hour trip to have tea with the pa­tient's mother.

"In all clinical work, both on the wardsand in the clinic, a well-trained socialservice worker is available for investiga­tion of the environment of the patient.Conferences with the students on stichmatters are routine."

A different point of view is implied inthe significant number of schools thatregularly offer opportunity for direct en­tree to the homes of patients and theirfamilies. Still another defense of theconcept of teaching "extra-hospital" med­icine is summarized in the teaching ap­proach of Dr. John PaUl, professor ofpreventive medicine at Yale (Yale J. ofBioI. and Med. 22: 199, 1950).

Dr. Paul expresses the opinion thatpreventive medicine may be developedbest as an academic discipline in a medi­cal school through the avenue of clinicalepidemiology or endemioloiO'. These arethe modern terms which describe theecology of human disease; that is, thecircumstances under which any diseaseor injury occurs.

"•.. if one is willing to study the cir­cumstances under which a given diseaseoccurs, one should be in a better positionto prevent it, according to the clinical

41

ao<.l:11::(1)

a8o

Q

principle that treatment logically followsdiagnosis. This ecological approach tomedicine is timely since during the pastgeneration medical practice and clinicalinstruction in medical schools have cometo be centered in hospitals. Modern medi­cine, having become more and more ahospital activity, demands that the ap­prentice work of third and fourth-yearmedical students be almost entirely con­cerned with sick people in a hospital bedor sick people in the dispensary. Thesesick people are isolated 'specimens.' Theyare segregated from their environment,removed from the circumstances underwhich they became ill, separated fromtheir families, stripped even of theirclothes-all of which is done to create aproper atmosphere for diagnostic studyand careful management on the physi­cian's part, free from outside distractions.It may be trite to point out that theseoutside 'distractions' are the very thingswhich the modern doctor, or the studentinterested in preventive medicine, needsto study also. If one is to handle patientsadequately, it is necessary to bring clini­cal judgment to bear not only on thepatient, but also on the circumstancesunder which his illness arose.

"There is nothing particularly originalabout this. It is and has long been theheart and soul of family practice, but ithas been gradually eliminated from hos­pital practice where analytical techniquesfor the examination of the patient or ofspecimens have come to dominate thefield of internal medicine. A plea forthis 'return to the soil' attitude may soundlike a plea for a 'dead' period in Amer­ican medicine such as the one whichoccurred in Germany at the beginning ofthe eighteenth century-a period with apoverty of observation and a wealth ofspeculation. Possibly so, but I wouldregard it as a plea for a more compre­hensive or integrative type of medicine inpreference to the analytical approach sopopular in the past decades. That Amer­ican medicine needs something of thistype has been expressed elsewhere.

"And yet one might well raise the ques­tion here as to whether the need for re­lating the patient to his native environ­ment and all its attendant circumstanceshas not been the very thing which hasbrought social service departments intobeing in most good hospitals, and, I pre­sume, all teaching hospitals. Such de­partments have proven indispensable, buta point I wish to make is that the exis­tence of a local department of social

42

service in a teaching hospital does notrelieve academic clinicians of their re­sponsibilities regarding 'extra - hospitalmedicine.' Physicians cannot put thewhole responsibility of social medicine inthe hands of lay social workers."

Data: Of the 64 schools participating inthe inquiry, 29 report the regular, re­quired practice of students visiting thehomes of patients and their families. Somehave multiple exercises of this type. Nineschools are nearing the point of institutingsuch programs, some of them quite am­bitious in scope. StilI other schools haveelective programs or home visiting as aninconstant feature, and only 19 schoolsreport that there is no visiting to thehomes of patients. Even among the latterare some who arrange for home visitingas a demonstration of the function ofpublic health personnel such as the visit­ing nurse. These have not been includedin this analysis in favor of limiting con­sideration to situations where a student­patient relationship is developed.

Also reported by several schools aretheir instructional programs in communityhealth activities. Since these were aninconstant feature of the replies received,comments will be restricted to a 'fewsel..ected cases.

There were virtually no replies to thequestion concerning adaptation of pro­grams of medical care conducted for rea­sons of research in which medical stu­dents might have opportunity for directparticipation.

The most striking feature of the repliesreceived is the apparent degree of currentinterest and activity in the teaching ofsocial and environmental medicine. Therehave been many recent changes in theapproach to this subject since publicationof "Widening Horizons in Medical Edu­cation" in 1948.

The information collected will be pre­sented under the following headinis:

1. Role of professional staff in socialand environmental studies.

2. Status of students in extra-muralstudies.

3. Duration of extra-mural case studyprojects.

4. Administrative arrangements (spon­soring departments).

1. Role of Professional Staff:(a) Physicians-The usual supervisory

functions of the physician are so obviousa$ not to reQuire elaboration. In thedomiciliary medical care programs thereis an increasing trend in the use of resi-

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

dents, both general practice and specialtytype, and of fellows.

(b) Social workers-The activities ofthe medical and psychiatric social workassociations in inquiring into their ownroles in such instruction is reported else­where. Medical social workers cospon­sored the study that culminated in publi­cation of "Widening Horizons in MedicalEducation."

Many schools reported the active par­ticipation of social workers in the selec­tion and assignment and co-supervision ofstudents in their daily case studies andin the special projects as well. The fullrange of the kinds of teaching exercisesin which social workers participate isbest described in the section of this reportdealing with the activity of the AmericanAssociation of Medical Social Workers.

Visiting nurse-In the main the visitingnurse participates in teaching by takingstudents on her daily rounds for the dualpurpose of demonstrating her functionand relation to the medical care teamand, secondly, to reveal either the com­mon or the more serious social and en­vironmental conditions to be found inhomes.

Certain extensions of her usual functionwere mentioned. At one school the nursereports her observation of the student'smanner and acceptance of the problemsin the home, the degree of his interestand his reaction in general. At SouthernCalifornia the nurse introduces the stu­dent to the patient in the home for thepurpose of examining and studying therole of environmental and social factorsas they contribute to illness. At one in­stitution the members of the visiting nurseservice, through their contact with one ormore members of an indigent family, re­cruit the entire family for a completemedical and social diagnostic study bystudents under the direction of collegestaff. The subsequent recommendationsfor continuing care are implemented bythe nurses through the ordinary channelsavailable to indigent patients.

2. Status of Medical Students:As is well known in hospital practice,

clinical clerks are commonly addressed as"doctor" by patients. This designation isless acceptable in an extra-mural situa­tion, particularly in instances where thestudent has not had much prior contactwith the patient; in cases where continu­ity of contact is. to be established thereis a tendency to introduce the studentwith a definitive title which describes hisstatus in terms of a useful function. A

62m ANNUAL MEETING

term increasingly employed is "familyhealth advisor." This title makes clearthat the student is not a medical practi­tioner to the family, but has only anadvisory function concernina the healthpromotion and protection of the family.What advice is offered is, of course, underfaculty supervision.

At Cornell two-thirds of the third-yearclass elect to serve as family health ad­visors to designated families over a periodof two years. Each student makes acareful study of the social and economicsituation of the family: housing, nutrition,sources of income and, particularly, theirmedical needs. The student works underclose supervision of a faculty advisor andhas the social and medical resources ofthe community at hand to aid him.

At Pennsylvania each year an increas­ing number of first-year students arepermitted to elect a four-year experiencein which each serves as family healthadvisor to a selected family willing tocooperate in the program. In this func­tion the student is there to guide thepatient through the intricacies of themore complex aspects of medical care,inform the clinic physician of his observa­tions in the home and aid in the inter­pretation of medical recommendationsmade.

In some schools, particularly those thatsponsor domiciliary medical care pro­grams, the student is spoken of as havingthe "status of a general or family doctor."By this is meant that he is a junior asso­ciate in the medical care of indigentpatients who are the responsibility ofphysicians who also visit in the home andwho usually have dual appointments withboth the school and the local officialagencies cosponsoring the medical careprogram.

A designation permitted in the Com­monwealth of Massachusetts is that of"medical assistant." Students who are atleast 21 years of age, have completed twoyears of their medical course and are un­der the direct supervision of practicingmembers of the faculty may be licensedas medical assistants. Boston University

.fourth-year students are so licensed in or­der to participate in the domiciliary med­ical care program.

One other type of function in whichthe medical student may see extra-muralservice is in health education. Fourthyear students of the College of MedicalEvangelists visit homes in the recruitmentof people living in a designated section ofthe city for the purpose of forming health

43

ao<.l:11::(1)

a8o

Q

study clubs, a project sponsored 'by theLos Angeles health department. Manyof the educational sessions of these clubsare conducted by the students themselves.

3. Duration of Extra-Mural Case StudyProjects:

If case study projects may be regardedas long-term when the duration of thestudent-patient relationship is in excessof one year, then there are relatively fewopportunities of this type in the medicalschools. Such experience is, of course,difficult to arrange but there seems to bemuch value in the very length and natureof an extended relationship.

Only two schools appear to provide asa requirement for every student a con­tinuing contact with a patient in excessof one year. There may be other insti­tutions, but if so it is not clear from thereplies submitted. Each third-year stu­dent at Boston University is assigned afamily from the home medical servicewhich he follows for two years. Thefamilies chosen include at least one mem­ber with a chronic illness and severalyoung children. A full discussion of thishighly developed program can be foundin the November 1950 issue of the Journalof the Association of American MedicalColleges by Dr. Henry J. Bakst.

At the University of Washington eachstudent is supervised in a medical-socialcase study by a clinician holding titles ininternal medicine and in public healthand preventive medicine. After the casehas been followed for approximately ayear with home visits and visitation tothe appropriate community agencies, thecase is presented during the public healthand preventive medicine externship inthe fourth year.

The family advisor programs of Cornelland Pennsylvania, which were mentionedabove, do not at present involve all stu­dents in a class. The majority of theCornell students have a continuing con­tact with a patient and his family over aspan of two years. The remaining thirdof the class performs a community sur­vey. At Pennsylvania successively largersegments of the first-year class are per­mitted to enroll in the elective four-yearfamily study.

A significant fact is the beginning ofa trend to the assignment of students topatients for long periods, in some in­stances to entire families. This yearthere will be a new ambulant and homecare service started at the University ofColorado in association with the Depart­ment of Health and Hospitals of the city

44

of Denver. As this program develops,third and fourth-year students will beable to establish a continuing relationshipto individual patients and their familiesfor extended periods. In Buffalo, in thepresent academic year, there will be in­troduced a program permitting a two­year continuing observation of a patientand family by each student. The latterprogram involves an arrangement inwhich case material is drawn from af­filiated hospitals with primary responsi­bility of the program charged to thecollege department of preventive medi­cine and public health, the other clinicaldepartments cooperating.

In the near future programs permittingextended contact are planned at Minne­sota, Kansas, Albany and Vanderbilt,among others.

At Minnesota, faculty approval hasbeen given to an elective course to besponsored by the department of psychia­try in which students, nearing the end ofthe second year, will be assigned to apatient in the prenatal clinic for the pur­poses of observing the course of preg­nancy followed by attendance at the de­livery and continued observation of themother and the newborn child throughthe remaining portion of the medicalcourse. The basis of the student contactwould be in the role of family healthadvisor.

Kansas plans the development of adivision of social medicine within the de­partment of public health and preventivemedicine in the supervision of two-year­long family studies. A third and a fourth­year student will serve as a team offamily health counsellors to selected fam­ilies residing in the local community whomeet the requirements for participation.'.rhe department of public health andpreventive medicine will be primarily incharge of the program with the otherclinical departments participating.

At Albany there is proposed a com­prehensive family study for each clinicalstudent with personal continuing contactwith a medically indigent family for aperiod of two years. This project is to beconducted cooperatively by the depart­ments of preventive medicine and publichealth, psYChiatry, medicine and pedia­trics. The central objective is to preparefuture medical practitioners to relate thehealth status of the patient to the socialand emotional factors which contributeto positive health or to those which accen­tuate an existing disease state. One novelaspect of the proposed program is the

~UTES OF THE PROCEED~GS

ao<.l:11::(1)

a8o

Q

working relationship to be developed withthe public schools and their school healthstaffs. In this connection the student willbe expected to follow through in consul­tation with the school physician, theschool nurse and the teacher wheneverspecific health problems and the familyenvironment appear related to the un­satisfactory performance of a child underobservation.

Vanderbilt plans to initiate a methodof teaching whereby students are intro­duced to a patient in the family group inthe latter's environment during the stu­dent's first year, with continuance ofthese contacts and experiences through­out the four years.

4. Administrative Arrangements (Spon­soring Departments):

The central point of the inquiry con­cerns the administrative arrangementswhich aid in the clinical instruction ofstudents under extra - mural circum­stances. The administrative arrangementsin question have to do particularly withaccess to patients and their families inthe natural environment of the home.These range from the simplest situationof a student making a prearranged post­hospital call to the more complex inter­departmental teaching projects of domi­ciliary medical care conducted as a sharedresponsibility with other communityagencies for medical care. Since in eachinstance these arrangements must be ini­tiated and maintained by a unit of theschool, this matter will be consideredfrom the point of view of the sponsoringdepartment. Reference also will be madeto the programs of some schools wherehome visiting by the student is inconstantor even negligible but where new inter­departmental arrangements aid in thecomplete study of the patient:

(a) Office of the Dean-It is not en­tirely clear either from the letters ofreply or from the medical college cata­logues, but the impression is gained thatin several institutions the dean and notone of the academic departments is re­sponsible for administration of instructionof the preceptorial type. This seems tobe identified with his executive function,even in instances where he also holds anacademic title. In view of the nature ofthe association and to the necessarilyscattered assignment of students to thegeneral practitioners serving as precep­tors, it seems logical that this arrange­ment should prevail.

Preceptorships are generally organizedto demonstrate general practice, to recruit

62ND .ANNUAL MEETING

to it and to give a picture of the socialand environmental aspects of medicineseen in the home as observed through theeyes of the family doctor. The durationof preceptorships ranges from four to 11weeks, and the experience is usuallyoffered fourth-year students. A strikingexception is South Dakota which organ­ized clinical clerkships for second-yearstudents through assignment of the latterto general practitioners for one month.This experience was reported by DeanSlaughter in the Journal of the Associa­tion of American Medical Colleges 24:193, 1949.

Vermont and Wisconsin are amongthose having the longest continuous ex­perience with preceptorial teaching. Thereis an increase in interest in preceptorshiptraining with Kansas, Oklahoma, the Uni­versity of Washington starting these pro­grams in recent years. The Stritch Schoolof Medicine planned to begin in the cur­rent academic year the practice of assign­ing one-third of the senior class to theoffices of general practitioners attachedto a school affiliated hospital.

(b) Medicine and Pediatrics - Theseclinical departments either alone or co­operatively with others frequently ar­range for individual case studies thatinvolve consideration of the family andhome.

At Rochester, students in recent yearsin the department of medicine have beenasked to study a single patient in con­siderable detail in order to determine howthe patient's illness might have been pre­vented and what measures could havebeen taken for better management. Thisalways involves contact with the patientand the family in the setting of the home.

A similar arrangement prevails at OhioState and Stanford in pediatrics. Suchexperience permits the student opportu­nity to form some understanding of theenvironmental influences which may alterand change the course of the child's con­dition. These include consideration ofthe social, community, parental, economicand hygiene factors. There is interestin helping the student understand theinterplay of the various forces and factorswhich tend to mold the child's life.

The most complex type of administra­tive arrangement, namely the operation ofa program of domiciliary medical care, isfrequently the charge of a department ofmedicine and this will be discussed underanother section.

(c) Psychiatry-The past decade haswitnessed the movement of psychiatry to

45

ao<.1:1

1::(1)

a8o

Q

a prominent place in medical education.In this development there is an increasingconsideration of the emotional problemsof the nonpsychotic patient. More andmore, psychiatry instructs jointly with oron the premises of other clinical depart­ments, sharing in the same teaching ma­terial. Examples of this are seen in theprograms at Southwestern, Duke, Hop­kins, Woman's College and Minnesota(mentioned above).

At Southwestern, under the directionof psychiatry, a course is offered in theart of medicine. This is a supervisedexperience in which each second-yearstudent is given a limited responsibilityfor two patients over one-half of a one­month period. The student's function isto coordinate the available medical in­formation usually obtainable from a vari­ety of sources in the interests of thesepatients. He is charged with summar­izing what has been accomplished, whatapparently remains to be done, what co­ordination of recommendations is desir­able and whether there are any misunder­standings or misinformation that need becorrected. It is the job of the student toknow the family and home situation sothoroughly that he can aid in the judg­ment of whether the medical care orderedis practical in terms of the actual situa­tion in which the patient lives. The stu­dents are surrounded with all facilitiesneeded for the care of patients, but theinitiative· is left to them. They are ex­pected to meet the needs of these patientsin the period of the study and to beavailable at all hours as any doctor would.The intent is not to teach psychiatry butan attitude toward people-how to ap­proach patients, how to establish a goodrelationship. Preparation for this comesin prior lectures and case demonstrations.

At Duke there has been in existencefor about four years an experimental pro­gram in defining and infiltrating a com­prehensive approach into the routinemedical practice of a teaching hospital,as well as testing the instructional meth­ods of highest validity in this approach.This is done through operation of a com­prehensive medical clinic in the medicalwards and outpatient department by apsychiatrist director, three fellows in psy­chosomatic medicine, three psychiatricsocial workers, two medical social work­ers, two psychosomatic nurses, one ofwhom is a public health nurse, and aclinical psychologist. The group's experi­ence and conclusions to date are publishedin the North Carolina Medical Journal

46

11: 615, 1950, by Dr. M. H. Greenhill andhis associates. This article points up sev­eral pertinent aspects of this subject andcertain of their thoughts are abstractedor quoted below:

Comprehensive medicine is held to bea method of recognizing and treating allthe physical, social and emotional vari­ables which are an integral part of theprocesses of health and disease in theirorder of relative importance. These proc­esses must be considered in terms of therelative values of the several componentsof the living organism. These componentsinclude physiological and biochemical fac­tors, symptom manifestation, mechanismsof adaptation to stress, inter-personalrelationships, and social and emotionalstimuli and reactions.

The problem of such teaching is adifficult one in medical schools at thepresent time because of preoccupation byinstructors with the physical manifesta­tions of disease. The approach of manyteachers is apt to be a monistic one ofsimple cause and effect. They lack amulti - dementional approach, and theother two variables-the social and emo­tional - require consideration of threeareas instead of one. A reaction of in­security appears even among the teacherswhen they find that in many cases thephysical area is no longer the supremevalue and is even distorted and maderelatively less valid by the influence ofthe other two areas upon it.

"In recent years teachers of preventivemedicine and public health have madeimportant contributions to the knowledgeof comprehensive medicine. These con­tributions have been mainly theoreticalin terms of the development of conceptsof social medicine. Emphasis has beenplaced upon the importance of the studyof health as well as disease, and on theinfluence of social pathology upon healthand disease. But in such an approachthe emotional components have been rela­tively neglected, and knowledge of theindividual has been sacrificed for anapproach to the group. Social medicine,therefore, has not achieved comprehen­siveness in its practical function, althoughtheoretically the individual and the vari­able of his emotions have been consid­ered. Departments of preventive medicineand public health in a very few schoolsof medicine incorporate the concept ofthe theory and practice of social medicinein their curriCUla, but this is, in the main,an unachieved idea!."

The segmentation of the disciplines of

l!INUTES OF THE PROCEEDINGS

ao<.l:1

medicine has led to assignment of thisphase of teaching to the psychiatric cur­ricula of medical schools. Psychiatry,dealing as it does with so many obvioussocial and emotional problems, has beenthe first of the clinical disciplines to de­velop techniques for their handling. Thereis no basic reason why psychiatry aloneshould attempt to be the only disciplineto handle them. "This concept is leadingto a reorientation in medical education.Impetus is given to this by the increasingawareness of the necessity of consideringthe social and emotional components inthe disease process of every patient andof the wisdom of dealing with the patientby a holistic approach. Hard reality, out­lined by statistical evidence, adds pres­sure to the necessity of infiltrating a morecomprehensive approach into the diag­nostic techniques and treatment skills ofall types of medical personnel, in additionto those being trained in the psychiatricdisciplines. There are not now, and itseems unreasonable to expect that therewill be in our lifetime, enough psychiatricpersonnel to take responsibility for themanagement of the emotional problemsof sick individuals. The trend now is totrain non-psychiatric medical personnelin orientation and techniques to be util­ized in the evaluation and managementof such patients. Such a trend is de­signed to prepare general practitioners ofmedicine, hospital nurses, public healthofficers and nurses, and specialists inother disciplines of medicine to performa triple task; namely, that they them­selves deal with minor psychiatric prob­lems, evaluate and manage the emotionaland social components in any patient withany disease and, finally, contribute to themaintenance of the emotional health inpatients and their families. It is obviousthat many problems take root here. Forexample, is it possible for non-psychiatricmedical personnel to perform these func­tions; what are the limitations of theseroles; and, finally, how can these func­tions be taught with the limitations oftime imposed on such education and inface of the emotional resistance whichnon-psychiatric medical personnel raiseagainst such an orientation?"

So far as the instruction of undergradu­ates is concerned, the comprehensivemedical group begins with one quarter ofthe second-year class. Twenty hours ofinstruction is given to this part of theclass in physical diagnosis. This samesegment of the class is followed in thethird and fourth years, having a variable

62ND ANNUAL MEETING

number of hours of instruction in option­al group conferences and in individualsupervision. The entire third and fourth­year classes are given approximately 14hours of instruction by the comprehensivemedical group in small groups duringclerkships in medicine.

Johns Hopkins School of Medicine car­ries on in the medical clinic an inter­departmental teaching program in whichthe social, environmental and economicaspects of illness are stressed. Certainfeatures of the administrative arrange­ments employed are of interest. Theseinclude the group practice type of or­ganization of the outpatient department;sponsorship of the course as a joint ven­ture of the departments of preventivemedicine, medicine and psychiatry, anintegration which is aided by the practiceof academic appointments in all threedepartments for key personnel togetherwith financial support from all three de­partments. The optimal time in the cur­riculum for such instruction is thoughtto be that part of the medical coursewhere the student first encounters re­sponsibility for the care of patients in theoutpatient department. The group prac­tice nature of the medical clinic has fa­vored the development of the role ofsocial workers as major therapeutic agentsto an important degree. Each studentcompletes a single, intensive, major casestudy in which visits to the home areoptional. Discussion seminars and case ~

presentations are employed to bring outthe significance of the major and moreimportant social and environmental prob­lems in medical care.

Woman's Medical College of Pennsyl­vania has three arrangements permittingaccess of the home to the student. Oneof these involves a comprehensive studyof a patient on the medical ward in whichspecial emphasis is given the psychoso­matic components. A full-time psychia­trist serves as consultant to the studentin the course of the study, and visits tothe home and family are made in thecompany of a social worker.

Preventive Medicine: The designationpreventive medicine is used to identifyall academic departments representingthis area of instruction, whether knownby those or other titles, and whethercombined with public health or any otherdepartment.

Of all the units of the school concernedwith instruction in the social and environ­mental aspects of medicine, preventivemedicine appears to be the most active.

47

ao<.l:11::(1)

a8o

Q

It is obvious that this should be the casein view of the usual responsibility of thisdepartment for presentation of commu­nity health problems and activities; also,teachers of preventive medicine are themore ready to consider and view peoplein their native environment. Of moresignificance is the apparently increasingrate at which preventive medicine is as­signed responsibility for conducting casestudies and demonstrations, or for co­ordinating a teamwork approach to thecomplete study ot the patient, with specialemphasis on the social and environmentalaspects.

The dilemma of preventive medicinehas been and in some areas continues tobe that of difficulty in access to patientsfor a department where the need is recog­nized of incorporating in their programan experience involving personalizedclinical preventive services. This has themost meaning to a student when it ispart of a comprehensive approach in casestudy.

In overcoming this difficulty an inter­esting variety of administrative arrange­ments have been developed which permitthe teaching of preventive medicine at aclinical level.

For purposes of discussion, it is pos­sible to consider these arrangements intwo categories: (1) situations where de­partments of preventive medicine havedirect access to clinical material as foundin the clientele of health departmentsand other community agencies, and (2)situations where the clinical material usedin illustration of the teaching of preven­tive services has its origin in teachinghospitals.

S eve r a I departments of preventivemedicine sponsor clinical clerkships, anda common practice is to assign studentsto health department clinics for the op­portunity of observing the personalizedhealth services provided by such agencies.The breadth and variety of teaching ma­terial would seem to vary with localcommunity organizational practices sincein some the functions of health and hos­pitals are combined in a single depart­ment. This seems implicit in the titlesof the local official agencies but may haveno meaning since it was not discussedparticularly by those responding to theinquiry.

While the patient material seen in ahealth department clinic is most usefulfor demonstration of programs of com­municable disease control and of themaintenance and promotion of health

48

through maternal, child, nutrition andother clinics, the specialized nature ofthe medical service offered may at thesame time limit the degree to which pa­tients may be used for purposes of com­prehensive case study. This may be oneexplanation of the frequent use of hospi­tal clinical material in special medico­social case studies in preference to thatavailable in the health department wherecollege preventive medicine is associatedand may be physically housed. Otherapparent reasons for choice of hospitalclinical material may be the relativelymore complete backlog of informationalready available in the record of thepreviously hospitalized patient.

One example where health departmentclientele has been used as a source forcomprehensive case studies is at the StateUniversity at New York City. To meetthe teaching need of access to entirefamilies, an extension of the function ofthe visiting nurse was devised in whichselected indigent families having manymedical and social problems are recom­mended by the nursing service for eval­uation by the college department. Thestudent is introduced in the home by thevisiting nurse, and he obtains throughrepetitive visits as complete informationas possible of the medical and socialstatus, relationships and needs of eachmember. Each student is supervised byan internist and also available for studentconsultation are a psychiatrist, pediatri­cian and obstetrician. A social workerarranges for personal contact for the stu­dent with community agencies havingpresent or past contact with the family.Definitive recommendations for therapyand continued care for the family areimplemented, with the advice of the socialworker, by the visiting nurse through theusual agencies for medical care availableto indigent patients in a large city.

Rather few institutions report the as­signment of students to the study ofostensibly well people. Opportunity forthis seems implicit in any situation pro­viding extended contact with families,especially in the domiciliary medical careand family advisory programs. The Uni­versity of Pennsylvania reports that intheir four-year family study the elementof health maintenance is being introduced.Jefferson Medical College reports that itsdepartment of preventive medicine is as­sociated with a unit of the health depart­ment which has a program catering toapparently healthy persons. It is knownas the Health Maintenance Clinic and to

MINUTES OF THE PROCEEDINGS

:::o·r;j.rJ)

§.\-;.

(1)­0..'

......;:S.o..s:: .t::~.

'"d(1)"u;:S:

'"do\-;

0..(1)\-;

(1)..0.o·..............oZ

ao<.l:11::(1)

a8o

Q

an increasing degree members ot familygroups are seeking the service of thisclinic. Students act as clinical clerks,performing health examinations, and adetailed study and inquiry into individualbehavior and environment are included.The Health Maintenance Clinic is beingused as an experimental laboratory inthe study of procedure in the examinationand care of the healthy person.

At Tulane, third-year students are as­signed to a preventive medicine clinicfor the purpose of studying the ostensiblywell person with periodic group discussionof the patients examined and inclusionof reference to the social aspects involved.

Among other phases of its program,Wisconsin reports two features that aresomewhat unique. For a limited periodsenior students participate in the medicalcare and health advisory functions of theUniversity Student Health Service. This,of course, encompasses a group of essen­tially healthy young adults and a type ofclinical and social problem different fromthat encountered elsewhere in the medicalstudent's experience. Another feature isadjustment of schedules permitting par­ticipation of students in epidemiologicfield studies depending upon the time ofoccurrence of specific situations in thefield.

Schools in addition to some of the abovewhich use health department clientelefor social and environmental case studiesare State University at Syracuse and theUniversity of the Philippines.

At State University at Syracuse, thestudent is assigned a case record from thefiles of the Syracuse Department ofHealth with responsibility for collectingfull information pertaining to this pa­tient. In the course of working up thedata for presentation to the class, visitsto the home of the patient and to thevarious community agencies are involved.At the University of the Philippines, stu­dents visit the homes of selected patientsregistered in the clinics of the WHO­UNICEF Rural Health Demonstration andTraining Health Center Program at Que­zon City. In addition to this medical­social study, each student is required tocomplete a sanitary survey of the com­munity where he expects to practioemedicine.

Cincinnati, Albany and the State Uni­versity of New York report programsthat involve the use of community agen­cies in the instruction of preclinical stu­dents, each for somewhat different pur­poses. Beginning in 1939 and continuing

62ND ANNUAL MEETING

to the present, an extra-mural program inpreventive medicine and public healthhas been conducted for second-year stu­dents at Cincinnati; 120 hours are as­signed for this purpose. Visitation to awide variety of community health ac­tivities are the essential feature of thisprogram. The areas covered in these fieldtrips require consideration of the socialand environmental aspects of medicalcare, significant environmental factors,etc. A monograph describing this pro­gram was published by Dr. Alfred Korachin The Medical Bulletin of the Universityof Cincinnati, Vol. 9, October 1942.

At Albany, for the purpose of devel­oping attitudes and understanding on thepart of students conducive to cooperationwith social work agencies and to stimu­late interest in the social and familialbackgrounds of patients, there has beenestablished a new type of course for sec­ond-year students. Each student spendsnine to 11 half-days observing in one ofthe official or voluntary health and wel­fare agencies. After sufficient orienta­tion, students are assigned places on theagency staff and are permitted to carryon some elementary social work activities.

At the State University of New York,a limited number of first and second-yearstudents may elect assignments to familysocial agencies and participate in thesolution of short-term problems of se­lected families. The purpose is not toacquaint students with community agen­cies but to provide experience in the artof establishment of a professional rela­tionship. The family agency is chosenas a locale in which the beginning studentmay be supervised in a situation wherehe has the status of a participant in thecare of someone under stress.

In order to obtain access to the clinicalmaterial found in hospitals and to teachin cooperative association with the otherclinical departments, the following typesof administrative arrangements are em­ployed by departments of preventivemedicine:

(1) Instruction of students on the timeassigned to other clinical departments.For example, at Colorado, among others,staff from preventive medicine teach di­rectly in the wards and clinics of otherdepartments.

(2) A system of dual appointments forpreventive medicine staff in one of theother clinical departments. This has beendescribed above in the examples of theUniversity of Washington, Johns Hopkins,etc., and is a well known practice.

49

ao<.l:11::(1)

a8oQ

(3) Clinical appointment in multiplehospitals for the professor of preventivemedicine. For example, in the plan ofreorganization of the department of pre­ventive medicine at Harvard in 1947, itwas recommended that there be soughtmore integration of the teaching of pre­ventive and curative medicine and themedical sciences. A practice which fa­cilitates accomplishment of this purposeis the award of medical appointments tothe professor of preventive medicine atseveral of the hospitals affiliated withHarvard so that in ward rounds and con­ferences the preventive point of view andthe significance of environmental factorsmay be stressed.

(4) Administration of preventive medi­cine as an integral part of internal medi­cine. This is the case at Yale, theUniversity of Chicago and Southwestern.At Yale, preventive medicine is taught atthe patient's bedside and the emphasis ison the contribution of clinical epidemiol­ogy in the comprehensive approach tothe patient. The procedure employed isthe following: in a weekly preventivemedicine seminar for third-year students,discussion starts with a critical reviewof the accuracy of the diagnosis and pres­entahon of what is known about theepidemiology of the disease in question.If possible some pertinent data are shown,either on a lantern slide or in tabularform on a blackboard, to indicate certainknown circumstances under which thedisease in question usually occurs, togeth­er with a listing of the various factorsthought to be of etiologic importance orof importance as predisposing elements.The past history of the patient is thenreviewed step by step in the light of theepidemiological data; the patient's presentcondition is reported and the prognosisdiscussed. These are reviewed at lengthbefore the attempt is made to predict howthe situation which led up to the patient'sillness might have been altered, how thesituation should be handled from thestandpoint of prevention after the patientleaves the hospital, and how a similarsituation with another potential patientcould be handled.

The University of Chicago is graduallyenlarging its preventive medicine staffand greater use of the outpatient depart­ment is planned in the teaching of socialand environmental medicine. The func­tions of the division of preventive medi­cine at Southwestern are changing, aswill be reported below.

(5) Interdepartmental teaching in

50

which preventive medicine is a partici­pant is a common practice. In some ofthe formalized arrangements mentionedabove, cooperative teaching is but one ofthe essential elements. Reference is hadhere more to interdepartmental teachingwithout the prerequisite of hospital oracademic titles or of any other formalarrangement and where pSYChiatry, medi­cine or one of the other services assistsin the teaching programs of preventivemedicine and vice versa. For example,at Illinois during the outpatient service,senior students are assigned to patientsjointly studied by staff from preven~ive

medicine and psychiatry. Each studentvisits the home and family and completesa study for presentation at a conferenceattended by representatives from preven­tive medicine, psychiatry and socialservice.

(6) Use of the hospitalized or the post­hospital patient for socio-medical casestudies. This is one of the more commondevices employed by preventive medicinein clinical case study teaching. In mostinstances such patients have been theobject of previous study by clinical de­partments other than preventive medi­cine. Washington University, New YorkUniversity, New York Medical College,Maryland and Buffalo are examples ofinstitutions conducting these case studies.

At Washington University there is ex­tensive teaching of social and environ­mental factors in the preventive medicineclerkship. The student engages in oneor more socio-medical case studies utiliz­ing patient material which he has seenduring other clinical clerkships. Studentsinterview the patient and family in thehome, representatives of schools andchurches and any social agencies withwhom the patient may have had priorcontact. The stUdent must make an eval­uation of the social and environmentalfactors determining the occurrence ofillness and conditioning medical care. Bysuch means he comes to know the impactof illness on the patient, his family andthe community. There are 12 seminarsdealing with social and environmentalfactors-four of them devoted to psycho­somatic influences as they pertain tomedical care.

At New York University, Dr. H. E.Meleney and Dr. H. Mortara have justfinished a five-year review of their ex­perience with medical-social family stud­ies. During the fourth-year clerkship,students are assigned in pairs to the studyof a family to give the student under-

~TES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

standing of the emotional, social, environ­mental and economic factors in the medi­cal problems of patients. In addition tomaking the student aware of the needof understanding a patient in relation tohis family and total environment, theexperience also demonstrates the functionof the social worker in a medical setting

. and the use of community resources. Themajority of patients come from BellevueHospital, and others are derived fromfour other sources. The medical studentsreview the medical and social servicerecords of the principal patients and visitthe home of the family in the companyof a social wprker. Subsequently, thereare field trips to community agencies andconsultations with the supervising physi­cians. A report is submitted and madethe basis of case presentation at a subse­quent student conference.

At New York Medical College, studentsvisit in the homes of patients of the EastHarlem District Health Center and of theFlower-Fifth Avenue Hospitals. At thelatter each student is assigned three pa­tients by the social service departmentof the hospital with summaries and rec­ords of the information available. Thefamily is informed that a member of theclinic will visit, and students on theirfree time visit the home and write up areport in terms of a common guide sheetfor presentation at seminar meetings at­tended by the professor of public healthand the social service staff.

At Maryland in the course of confer­ences conducted by the Department ofHygiene and Public Health, case presenta­tions are made by students on patientsderived from the hospital ward service,whose home environment has been stud­ied under the supervision of the socialworker of the Western Health District.

At BUffalo, patients derived from theoutpatient departments of pediatrics,medicine or surgery will be assigned tostudents beginning this year for the pur­pose of a two-year continuing contactand study of the family. Primary re­sponsibility and supervision of the pro­gram will be in the hands of the depart­ment of preventive medicine and publichealth.

At Louisiana State, the home visit to adischarged hospital patient required bythe department of neuropsychiatry issimultaneously used as an environmentalcase study by the department of publichealth and preventive medicine. Thestudent is asked to note and evaluate thepublic health problems that exist or the

62ND ANNUAL MEETING

environmental and social conditions thatmay be of importance with regard topotential health problems as well as thosepresently existing. These observationsare all included in the write-up of thisvisit. •

(7) Employment of the case stUdymethod as a means to an understandingof the role of community health agenciesin medical care and the promotion ofhealth. Stanford, Harvard and GeorgeWashington are examples of schools withsuch programs. The course at Stanfordis entitled "The Patient in his Environ­ment" and is described in "WideningHorizons in Medical Education," pages127 to 135. The objective is to familiarizethe students with the responsibilities ofthe medical profession in the presentsocial structure; the influence which thepractitioner exerts on his community, andthe social-environmental influences whichaffect each patient's illness; also, to ac­quaint the students with the resources orfacilities which the community providesin meeting these responsibilities.

Students in groups of three are as­signed a patient seen formerly on thewards for complete study. Each casepresentation is used as a point of depart­ure for a general discussion of the workof a particular welfare agency, which inturn is related to the work of otheragencies in the same field. At times arepresentative of the agency involved isasked to attend and participate in thediscussion.

At Harvard, one phase of the course inpreventive medicine involves a survey ofcommunity agencies available for medi­cal and health care. Preparation for itcomes in a preceding lecture and paneldiscussion course and this project teststhe ability of students to apply the prin­ciples taught to the actual care of patients.This is known as a health resources sur­vey, and replaces the former sanitarysurvey. Four hypothetical cases are chos­en which highlight the more common andtypical problems met in ordinary medicalpractice. In each case the student isasked to prepare a detailed quantitativeand qualitative statement of the diag­nostic, therapeutic and preventive serv­ices which should be available for theoptimal care of each patient in the lightof current scientiflc knowledge. Havingoutl!ned the optimal facilities, the studentvisits a community of his own choice,possibly one where he may start his pri­vate practice, and performs a survey ofthe facilities which actually exist for the

51

ao<.l:11::(1)

aBo

Q

care of four such patients. This is fol­lowed by a discussion of the differencesbetween the optimal and actual facilitiesand, finally, practical suggestions con­cerning improvement of existing medicalservices. ~

George Washington School of Medicineis introducing this year a health resourcessurvey in the teaching program conductedby the department of bacteriology, hy­giene and preventive medicine. The de­cision to employ a health resourcessurvey as one device for understandingsocial and environmental medicine ap­pears to have its origin in two circum­stances. One is the apparent merit in theteaching method itself, and the otherseems to be an administrative adaptationto the fact that at this school the teachingof clinical preventive medicine is an in­tegral part of the functions of each ofthe clinical services. The department ofbacteriology, hygiene and preventivemedicine has no direct clinical responsi­bility, although it does teach at selectedclinical levels in demonstration of per­sonalized health services through associa­tion with a local but somewhat distantrural health department. The health re­sources survey apparently is suitable forapplication either in the immediate clini­cal facilities in which the medical schooloperates or in the community where thestudent visualizes his future practice willbe located. It involves considerable com­munity but obviously no home contactsin view of the hypothetical nature of thecase histories.

At Cornell, about one-third of the classchoose to prepare an extensive surveyof the health resources of a community,but this is not done through the mediumof actual or hypothetical case studies.

(8) Assignment to preventive medicineof administrative responsibility for am­bulant and home care patients. Suchprograms are about to start at Colorado,Southwestern and Washington University.

At Colorado, in order to realize theteaching objective of training students togive health supervision to families andindividuals on a continuing basis ratherthan as an episodic affair, arrangementshave been worked out by the medicalschool with the Department of Health andHospitals of the City of Denver. Themedical school is committed to the de­velopment and operation of trainingprograms for the general physician atboth the undergraduate and graduatelevels. The city of Denver must providecontinuing general medical services to a

52

large portion of the indigent and medical­ly indigent of the city. It was clear thata combination of the resources of the twoagencies would be to the mutual adv:an­tage of each. This led to the administra­tive arrangement of the establishment ofthe general medical clinic in the depart­ment of health and hospitals. This clinicwill act as a single portal of entry anddischarge for the medical care services ofthe department of health and hospitals,and will replace the general outpatientdepartment of the Denver General Hos­pital. It will be the administrative re­sponsibility of the department of healthand hospitals. Its professional staff willbe members of the faculty of the schoolof medicine and organized as the pre­ventive medicine and public health medi­cal staff of the department of health andhospitals. The chief of this division isto have the title of director of professionaland educational services of the clinic andis to be a member of the university de­partment of preventive medicine andpublic health.

Commencing possibly in the presentacademic year, there will be an ambulanthome care program at Southwestern con­ducted under the auspices of the divisionof preventive medicine in the departmentof internal medicine. At WashingtonUniversity there is strong likelihood thatthe department of preventive medicinewill be responsible for the professionalservices rendered in the outpatient de­partment of the medical school coordinat­ing all teaching of ambulant care andproviding students with some opportunityfor experience in the homes of patients.

Domiciliary Medicine: Schools report­ing programs of domiciliary medical careare Georgia, Tufts, Boston University,Nebraska, Vermont and the Medical Col­lege of Virginia. Reference has beenmade above to the proposed programs ofKansas and Colorado, the latter nowgetting under way.

Georgia has had a long and continuousexperience with domiciliary medicinestarting a large scale program of homecare of patients as a teaching device in1925. By virtue of a contract with thecity and county, the medical school enjoysthe privilege of exercising medical andsurgical control over all the free patientsin the city and county, and is responsiblefor the choice of the participating physi­cians. Each student spends a third of hissenior year in this prol'tl'am which isoperated by the department of medicine.A description of the values in this form of

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

teaching is found in the article "Domicili­ary Medicine at the University of GeorgiaMedical School," by V. P. Sydenstrickerand S. L. Lee, published in the Journalof the Association of American MedicalColleges in 1939.

The domiciliary medical service of theBoston Dispensary was established in1796, and medical responsibility for thework of this service was reorganizedunder the department of medicine ofTufts College School of Medicine in 1929at the time of the establishment of th~Ne~ England Medical Center. The pro­feSSIOnal personnel supervising the districtservice now consist of a medical super­visor, six full-time physicians, a groupof fourth-year medical students and afull-time social worker. The medical su­pervisor is a member of the staff of themedical center and of the faculty of themedical school. He is responsible for theadministrative and medical policies of theservice as well as the teaching program.There are six district physicians who areappointed to fellowships in domiciliarymedicine for a period of one year. Theyspend their mornings in the medical andspecialized clinics of the Boston Dis­pensary, and in other teaching exercisesat the New England Center Hospital.Their afternoons are devoted to makinghome visits to patients and acting aspreceptors to medical students. All newpatients seen by the students must bechecked by the preceptor after which thestudent may make followup visits alonereporting the progress of the patient t~the preceptor. Eight to 12 fourth-yearstudents are assigned to the district serv­ice for a period of four weeks. Theirmornings are spent with the medicalsupervisor and in outpatient work. Eachstudent undertakes a study of the socialsituation and related factors in one of thecases he has worked up medically. Thereare seminars which point up the sig­nificant medical and social problem.

For three-quarters of a century, BostonUniversity and the Massachusetts Memo­rial Hospital have accepted responsibilityfor a domiciliary medical care programknown as the home medical service. Thiswas regularly a function of the depart­ment of internal medicine until its trans­fer to the department of preventive medi­cine in 1948. The home medical serviceministers to certain of the medically in­digent residing in an area one squaremile around the school with a populationof about 50,000 residents. In one yearrecenUy, there were 11,608 home visits.

62ND ANNUAL MEETING

Senior medical students are legally priv­ileged to practice as medical assistantsunder the supervision of registered physi­cians. Each student spends one monthon this service and may spend an addi­tional month on an elective basis. Thethird-year program of assignment of astudent to a family has been describedabove. The immediate objective of theservice is to give medical students, justas all departments combine to do in acollective way, an opportunity for fullcomprehension of the physical, psycho­logical and social aspects of medical care.The program is believed to be a practicalanswer to the problem of integrating thevarious phases of the medical curriculuminto a unified approach to the patient asa whole. The student is able to see ill­ness at its onset and to get some pictureof the varied and inclusive problems ofthe general practitioner. He sees thepatient in relation to others and there isless need to give didactic emphasis to thevery obvious social and environmentalfactors which exist. He becomes familiarin a practical way with utilization ofpublic and private resources, and finallyobtains the point of view that medicineis a social as well as a natural science.

For many years at the University ofNebraska there has been operated anout-call service which is part of thedispensary service. Indigent patients maycall and have a senior student visit intheir homes. The senior student studiesthe patient and makes recommendations,conferring with a supervising staff manto assist in the problem.

A domiciliary medical care programhas been associated with the Universityof Vermont College of Medicine for thepast 15 years. It is known as the cityservice and is housed in an outpatientdepartment under the direction of thecity physician, who is a member of thecollege teaching staff and devotes fulltime to this assignment. Senior studentsare assigned for a period of one monthto this service where they are on 24-hourcall. In the company of the city physi­cian they visit the city's indigent whoneed medical care. Complete studies aremade by the students who then discuss thesituation with the city physician, andarrangements are made for a plan ofaction in the care of the patient.

At The Medical College of Virginia,a home care program is administeredjoinUy by the Department of PublicHealth of the City of Richmond and themedical college. In the course of an

53

ao<.l:11::(1)

a8o

Q

eight-week clerkship, senior medical stu­dents spend one-third of their time inassignment to a home care program andthe other two-thirds in the general med­ical and medical specialty clinics. Initialhome visits are made by medical studentsin pairs in health department carsequipped with two-way radios. Follow­ing the home visit the medical findingsare reviewed with the residents or at­tending physicians, who return with thestudents to see the patient or makeother appropriate recommendations forthe care of the patient. There are weeklymeetings of the staff in which the patientsare discussed, and there are 16 seminarsat which the public health, as well as themore strictly medical aspects, are pre­sented in the case discussions of patients,their families and their problems. This isall operated as a function of the depart­ment of medicine.

Family Studies: There is a trendtoward a study of the family, not aloneas a means of indUcing students to enterfamily practice, but to make studentsaware that the problems of a patient areoften not understandable except in termsof knowledge about the family in whichhe lives.

Over a period of years. as judgedmerely from changes in teaching empha­sis, there appears to have occurred. insuccessive stages, the concern lest socialand environmental factors be ignored inplanning medical care, to the stage ofrecognition of need of an integrated andcomprehensive approach which equatessocial and environmental factors in termsand values comparable to the physicaland organic, depending upon individualcircumstances. Now there appears to bea movement toward the study of families,an indication of the inseparableness ofpatients and families. These are, for themost part, patient-centered studies. How­ever, one school assigns families withouta principal patient for the value thismay have in facilitating study of inter­personal relationships. Such study mayat times be impeded by setting up aprincipal patient relationship with thestudent or doctor.

There is also a trend in making medical­social studies, whether performed onpatients or families, a point of unityfor interdepartmental teaching. Thisseems to be evolving as the natural addi­tion of those skilled in the methods ofdiagnosis and therapy, plus those com­petent in handling emotional problems,plus those with a preventive point of

54

view and with competence and interest inthe host-environment complex.

The study of families is being devel­oped as a focal point of interdepartmentalteaching and of curriculum planning. Thisappears in the program planned at Cor­nell. In 1952 there will be introduced anew curriculum of coordinated teaching.One of the clinical clerkships in thesenior year will be a half-year in length.Such teaching will be centered in theoutpatient department of New York Hos­pital and will be participated in bymedicine, pediatrics and preventive medi­cine. Students will follow families as­signed from the outpatient department tothe home. Selected families will be givencomprehensive medical care, includinghome nursing and domiciliary care byhospital staff members.

Among the schools engaging in familystudies are Boston University, Pennsyl­vania, Cornell, New York University,State University at New York City. Buf­falo and others, particularly those withhome care programs. They are plannedin the near future for Vanderbilt, Kansas,Minnesota and Albany.

Communication with Related Profes­sional Groups: (a) Conference of theProfessors of Preventive Medicine. Cor­respondence was initiated with theofficers of the conference, Dr. JohnDingle and Dr. Ray Trussell. There isno other academic group as primarilyconcerned with the teaching of environ­mental medicine as the members of thisconference. From this correspondencecame an invitation to prepare an articlefor the June issue of the conferenceNewsletter entitled "The Social Environ­ment as a Concern of Preventive Medi­cine." This dealt principally with theactivity of the Association of AmericanMedical Colleges in environmental medi­cine and the relationship of the inquiryon administrative arrangements for suchteaching to professors of preventive medi­cine. Two members of the Committeeon Environmental Medicine have beenappointed members of the planning com­mittee for the five-day Conference onthe Teaching of Preventive Medicinewhich will be held in the fall of 1952.

(b) For many years the AmericanAssociation of Medical Social Workershas been actively interested in examina­tion of the teaching function of theirmembers in the medical colle2es. MaryL. Poole, University of Pennsylvania. ischairman of the present Subcommittee onParticipation in Teaching Social and En-

~TES OF THE PROCEED~GS

ao<.l:11::(1)

a8o

Q

vironmental Factors in nIness. In Janu­ary 1951 this committee summarized thefindings of a preliminary survey analyz­ing the variety of ways in which caseworkers participate in the teaching ofsocial and environmental factors. Aquestionnaire was addressed to the socialservice departments of the main teachinghospitals affiliated with medical schools,a total of 74 hospitals. Seventeen reportthat they are not participating in a teach­ing program, and many others had notreplied at the time of preparation of thepreliminary report. Consequently, theinformation obtained is based on the con­tributions of 28 institutions.

The variety of programs in which so­cial workers participate include the fol­lowing: lectures, case presentation forthe purpose of seminar teaching, super­vision in case study, class discussion,orientation, ward rounds and conferences,consultative function with respect topatients cared for on a home care pro­gram, clinic consultations, continuing ad­visory function to students assigned rolesof family health advisors and arrange­ment for participation in field visits.

Of the 28 hospitals replying to thequestionnaire, 10 reported that facultyappointments are given social workers inthe medical school. These appointmentsrange from lecturer to associate pro­fessor.

Activities of American Association ofPsychiatric Social Workers Committee onMedical School Teaching: Psychiatric so­cial workers have been involved activelyin medical school teaching for manyyears. The national professional organi­zation-American Association of Psychia­tric Social Workers, 1860 Broadway, NewYork City-has had a committee on socialwork teaching in medical schools since1948. In addition to the national organi­zation there are fifteen district branchesof A.A.P.S.W. in various cities throughoutthe United States, and two additionalbranches in the process of formation.

Mrs. Melly Simon of the Payne WhitneyClinic, New York Hospital (Cornell Uni­versity Medical School), was chairmanof the committee on social work teachingin medical schools in the academic yearjust completed. In a study of such teach­ing, the committee found that psychiatricsocial workers not only teach in psychia­try departments of medical schools butin others where the teaching of socialfactors in medicine, of people's motiva­tions, of social resources in general, etc.,are incorporated in the teaching program.

62ND ANNUAL MEETING

Increasingly over the past few years, andparticularly since conduct of joint meet­ings of the Psychiatric Social Workerswith the American Psychiatric Associa­tion, the feeling in the committee hasgrown that this type of teaching shouldnot be limited to psychiatry departmentsbut should permeate the medical schoolprogram, and that this teaching shouldbe shared intimately by both psychiatricsocial worker and medical social worker.Dr. Thomas Rennie of Cornell UniversityMedical School, and Dr. Howard W.Potter of the State University MedicalSchool at New York, the present psychia­tric consultants to this committee, strong­ly concur in the above.

In 1948 and 1949 the A.A.P.S.W. com­mittee on medical school teaching sentletters to all of the medical schools,principally to psychiatry departments, anda detailed analysis of the first 15 reportsreceived was made. This was done bytwo Columbia University graduate stu­dents in fulfillment of the requirementfor a Master's thesis for the ColumbiaUniversity School of Social Work. Copiesof the full report were sent to all themedical schools participating, and addi­tional copies are said to be available forconsultation.

One aspect of this report deals withthe generic nature of case work knowl­edge and practice, a feature which wassupported by examination of the specificcontent of teaching done by psychiatricsocial workers. The report also indicatedthat a comparison of the teacrJng contentoffered medical students respectively bypsychiatric and medical social workerswould be of interest.

In 1951, Miss Poole of the AmericanAssociation of Medical Social Workers,and Miss Heyman of the American Asso­ciation . of Psychiatric Social Workers,both on the staff of the University ofPennsylvania Medical School, began areview of the respective teaching settings,via the written material received by bothorganizations. They hope to select a smallgroup of medical schools where both med­ical and psychiatric social workers areteaching. Having done this, both organiza­tions hope to proceed jointly with alimited study of the teaching contentcovered by each group.

Another activity of value to psychia­trists and to psychiatric social workerswas the institution of joint sessions ofboth groups at the 1950-1951 meetings ofthe American Psychiatric Association forthe purpose of discussing certain problems

55

ao<.l:11::(1)

a8o

Q

in the education of the medical student.These meetings have been fully reportedand the minutes of the 1950 meetingpublished in the A.A.P.S.W. Journal, Vol.20, No.3, 1951. The second meeting'sstenotyped minutes were sent to eachparticipating medical school. This meet­ing dealt with the importance of provid­ing first and second-year students withopportunities to work with people, to de­velop a feeling for their professional roles,to acquire beginning skills in interview­ing, and some general understanding ofpeople's problems.

At the National Social Work Con­ference in Atlantic City in 1951, anevening seminar was devoted to an ex­change of experience among those iI).­volved in social work teaching in medicalschools. Tentative agreement was reachedon sponsorship by the A.A.P.S.W. of theregional conference, with eventual repre­sentation from these to the larger inter- .disciplinary meetings.Accepfance

The annual report of the Committee onEnvironmental Medicine was acceptedwithout revision at the Business Meeting,Tuesday, October 30.

Committee on Financial Aidto Medical Education

GEORGE PACKER BERRY, chairman: Dur­ing the past year the Committee on Finan­cial Aid to Medical Education has con­centrated on two lines of endeavor: (1)securing the passage of suitable federallegislation to provide emergency financialassistance to medical education, particu­larly the passage of S. 337 in the Senateand H.R. 2707 in the House, and (2)working in every way for the success ofthe National Fund for Medical Education,Inc. Since the prospects for financial as­sistance from federal sources through thepresent Congress are now very slim, andsince the National Fund, although makingprogress steadily, is doing so slowly, thecommittee recommends to the schoolsthat explorations also be pushed in otherdirections for the solution of their finan­cial problems.

The financial pli1{ht of the medicalschools continues to be desperate, par­ticularly in the case of the private schools.Increases in the funds to support researchthrough specific grants have had only aminimal effect toward ameliorating thetotal problem. Indeed, in a number ofinstances, the schools have been too poorto be able to "afford" accepting increased

56

support for research. Tax-supportedschools are somewhat better off in manyinstances, owing to larger appropriationsof state and municipal funds. While thetotal amount being spent through themedical schools has increased significantlyin the last few years, the march of infla­tion has obliterated the gains, which havebeen very uneven at best. Thus, the man.stem continues to wither while thebranches expand.

Federal Aid: S. 337, which had beenbrought out on the Senate fioor with thePastore amendment incorporated by theSenate Committee on Labor and PublicWelfare, was killed on October 4, 1951,the Senate voting down the amendment42 to 23.

Your chairman withdrew his supportof the bill in its amended form, as did thedeans of many medical schools, becausethe amendment so changed the philosophyof the proposed legislation that it becamea strong appeal for quantity at the ex­pense of quality. It seemed better to haveno bill at all than to have one embodyinga dangerous amendment that proposeda seductive stimulus to overexpansion.This point of view is enlaged upon in thedocuments attached as an appendix (seepage 58). These include an explanatoryletter prepared by the chairman on Oc­tober 9, 1951, setting forth in detail whathappened to S. 337 in the Senate onOctober 4, and accompanying copies oftelegrams and letters passing betweenyour chairman and Sen. James Mur­ray, chairman of the Senate Committeeon Labor and Public Welfare, and Sen.Robert A. Taft.

National Fund for Medical Education:Last spring, after some two years of em­bryonic life, the National Fund for Med­ical Education became a reality. With thevery substantial help of the AmericanMedical Education Foundation, estab­lished earlier this year by the AmericanMedical Association, the national fundwas able to announce publiclY last Maythat a total of $1,132,500 had been col­lected. This sum, in the form of initialClass A grants, was distributed to the79 medical schools of the country, $15,000to each four-year school and $7,500 toeach two-year school. This is a good be­ginning for which all the schools' ad­ministrators are extremely gratefUl.

It is noteworthy that the fund's trustees,in awarding these initial grants, stipulatedthat they were for the unrestricted useof the schools' teaching programs. Smallas these grants may be, it also is note-

~INUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

worthy that, for many of the schools,they will constitute the largest unre­stricted sums available for use during thecoming year. The unrestricted nature ofthe grants indicates a true appreciationby the fund's trustees of the dire needof the medical schools and in turn placesupon the schools an added responsibilityto continue to strive for the maintenanceof the highest possible teaching standardsand to improve them wherever possible.

While the accomplishments of the na­tional fund to date are modest, the poten­tialities of the fund for the future aregreat. It has many original aspects forincreasing financial support of medicaleducation in that it brings together manysegments of the community in a jointendeavor. One must not fail to realizethat it may be an effective instrumentfor educating the public about medicaleducation and its vital importance formodern society. It is sincerely hoped thatthe fund will continue to grow and to gainin acceptance by the public generally.

Because Chase Mellen Jr., executivedirector of the National Fund for MedicalEducation, will make a separate reportat the 62nd Annual Meeting of the Associa­tion, further elaboration herewith wouldbe superfluous. Meanwhile, your chair­man suggests that it would be in orderfor the Association to pass an appropriateresolution of thanks to the fund's trusteesand also for the schools' administrativeofficers to unite in their efforts to assistthe trustees in the task they have volun­tarily accepted to help the schools over­come their pressing financial difficulties.

ResolutIonsUpon the motion of Dr. Berry, resolu­

tions expressing appreciation to the Na­tional Fund for Medical Education and tothe American Medical Education Founda­tion were unanimously passed as follows:

"I move that the deans of the medicalschools, in assembly at French Lick fortheir 62nd Annual Meeting, unanimouslyexpress their sincere appreciation andtheir enthusiastic thanks to the trusteesand officers of the National.Fund for Med­ical Education for their devoted and time­consuming efforts, voluntarily assumedon behalf of the deans and their faculties,and for their effective help to the medicalschools in these times of crippling finan­cial distress."

"I move that the deans of the medicalschools. in assembly at French Lick fortheir 62nd Annual Meeting, unanimouslyexpress their sincere appreciation and

62ND ANNUAL MEETING

their enthusiastic thanks to the trusteesand officers of the American Medical Edu­cation Foundation of the American Med­ical Association for their substantial sup­port of medical education and for helpingto focus national attention on the seriousfinancial predicament of the medicalschools." .

DR. BERRY: The financial plight of themedical schools is receiving increasingand alarmed attention by the administra­tion of their parent universities. Note­worthy are the reports of the Commissionon Financing Higher Education. (Thecommission is an independent body spon­sored by the Association of AmericanUniversities and financed by grants fromthe Rockefeller Foundation and the Car­negie Corporation. It is engaged in a long­range study of the financial problems ofAmerican colleges and universities.) Inthe pamphlet entitled, "The Impact ofInflation Upon Higher Education," pub­lished by the commission a year ago, theimpact of rising costs and shrinking dol­lars was lucidly set forth. Last May asecond pamphlet entitled, "FinancingMedical Education," stressed the nationalnecessity of solving the financial predica­ment of medical schools. From the pointof view o( the parent universities, thisanalysis considered many of the factorscurrently undermining the security ofmedical education and suggested a vari­ety of remedies that deserve careful study.In this connection, the anticipated publi­cation within the year of the report ofthe Survey of Medical Education, with itsdetailed analysis of the problems in­volved, is eagerly awaited.

Many schools may be driven to in­creasing tuition fees. In the face of soar­ing living costs this expedient promiseslittle, for it will lead rapidly to diminish­ing returns both in terms of dollars andthe breadth of student selection.

Many schools are successfully appeal­ing to their alumni for annual contribu­tions. This source of additional supportdeserves full exploration.

By an effort to secure adequate re­imbursement for overhead in connectionwith the large annual grants flowing intothe schools to support specific researchprojects, there is hope for substantialrelief. This difficult problem deservescareful study; it must not be exploitedunfairly nor in a way to jeopardize re­search activities.

On these and on many similar ques­tions your committee hopes for your sug­gestions and the opportunity to benefitby free discussion.

57

ao<.l:11::(1)

a§o

Q

AcceptanceThe annual report of the Committee on

Financial Aid to Medical Education wasaccepted at the Business Meeting, Tues­day, October 30.

Appreclat'ollA vote of appreciation was given the

Committee on Financial Aid to MedicalEducation for its efforts in support ofSenate Bill 337.

APPENDIX-REPORT OF COMMITTEE ONFINANCIAL AID TO MEDICAL EDUCATIONI. Letter from Dr. Berry to the Deans

October 9, 1951Dear Doctor:

The present letter summarizes the fateof S. 337 in the Senate on October 4, itscurrent status, and the tole I played in"killing" the Pastore amendment.

On October 4, the Senate, by voice (un­recorded) vote, recommitted S. 337, Fed­eral Aid to Medical Education. Thismeans that the bill is being returned tothe Senate Labor and Public WelfareCommittee, but recommittal has been sus­pended by a motion (now pending on theSenate floor; may be considered at anytime) to reconsider the recommittal. Itseems very unlikely that the bill will passin 1951; there is only a remote possibilitythat it will cOme up again.

Senate discussion of S. 337 on October4 was complicated by Sen. John O. Pas­tore's (D., ·R.I.) amendment to provide$200 per existing medical student and$2,200 for each new student. (The un­amended bill had called for $500 and anadditional $500.)

I informed the Senate that I wouldoppose the amended S. 337 because theamendment so chanited the philosophyof the bill that it became a strong appealfor quantity at the expense of quality.My reasoning was that it is better tohave no bill at all than to have one em­bodying a dangerous amendment that isreally a seductive stimulus to overexpan­sion.

The Senate killed the Pastore amend­ment, 42 to 23, with the final vote asfollows:

FOR: Benton, Douglas, Green, Hayden,Hill, Humphrey, Hunt, Ives, Kefauver,Kerr, Kilgore, Langer, Lehman, Long,McFarland, McMahon, Monroney, Moody,Morse, Pastore, Robertson, Sparkman andStennis. AGAINST: Bennett, Brewster,Bricker, Butler-Neb., Carlson, Case, Con­nally, Dirksen, Dworshak, Ecton, Ellender,Ferguson, Flanders, Gillette, Hendrick­son, Hoey, Jenner, Johnson-Colo., John-

58

ston-S.C., Knowland, Lodge, Malone,Martin, Maybank, McCarran, McCarthy,McClellan, McKellar, Millikin, Mundt,Nixon, Saltonstall, Schoeppel, Smith-N.J.,Smith-N.C., Taft, Thye, Watkins, Welker,Wiley, Williams and Young.

Senators who were most active on thefloor in opposing the entire bill weresenators Dirksen, Taft, Carlson, Schoep­pel, Bricker, Capehart and Johnson ofColorado. Those most active in favor ofthe bill were senators Pastore, Lehman,Benton, Hill, Hunt, Kerr, Long andHumphrey. It is conceivable that someof those who voted against the amend­ment might have voted in favor of finalpassage of the bill if given the opportun­ity (Bulletin No. 34, October 5, 1951,from the Washington Office of the Ameri­can Medical Association, Joseph S. Law­rence, director.)

The following analysis of the situationis taken from Washington Report on theMedical Sciences (No. 226, October 8,1951, Gerald G. Gross, editor):

"The setback suffered by S. 337 hingeson Thursday's defeat, by vote of 42 to 23,administered to a committee amendmentgranting highest federal subsidies to pro­fessional schools that increased their en­rollments. Proposal of this amendment,described by WRMS two weeks ago (No.224), was a strategic move designed tocapture votes of Southern Democrats whootherwise might have opposed the billon anti-Ewing, anti-"socialized medicine"grounds. What happened was that thestrategy boomeranged, the amendment be­ing defeated and recommittal of the billbeing requested immediately afterwardby its floor manager, Sen. John O. Pastore(D., R.I.), because he realized that itwould be decidedly risky to let the billitself be brought up for a decisive votein this charged atmosphere.

"Highlight of Wednesday's debate wasSenator Taft's declaration that he nowopposes S. 337, which he formerly co­sponsored, as well as the proposed amend­ment to increase incentive payments tomedical, dental, nursing and other pro­fessional schools covered in this bill. Heclaimed that many of the medical deanslined up in support of the legislation,including Harvard's, Yale's and Cornell's,had informed him their support wouldbe withdrawn if the amendment wereadopted. He voiced anxiety that it wouldonly be an incentive to overcrowding and,referring to the bill proper, permit thegovernment to _intrude itself upon selec­tion of students.

MINUTES OF THE PROCEEDINGS

ao<.l:1

"On Thursday, when reconsiderationmotion by Sen. H. H. Humphrey (D.,Minn.) reopened debate after Pastore'smove to recommit had been agreed to,spirited verbal exchanges ensued amongTaft, Pastore, Humphrey and latter'sMinnesota colleague, Thye (R.). Pastorebitterly charged he had been abandonedby fellow members whose floor supporthe had counted on. Thye joined Taftin denying that the 'abandonment' wasbased on party differences, to whichPastore replied: 'Mr. Republican (ad­dressing Taft), I am not that naive.'Thye stated he was prepared to vote forS. 337, without the controversial amend­ment, and similar views were expressedby senators Ralph E. Flanders (R., Vt.)and Willis Smith (D., N.C.). Note: Twoadditional amendments, intended to berestraining influences, have been pro­posed, one by Smith and the other byJohnson (D. Colo.). Former eliminatesS. 337 language on schools' admission ofout-of-state stUdents; latter allocates op­erating funds to military budget, accent­ing emergency idea."

I should welcome your comments onthis sad situation.

Sincerely yours,GEORGE FACKER BERRY, M.D.Dean

2. Telegram Co Dr. BerryOctober 4, 1951

Early this afternoon the Senate of theUnited States will vote on S. 337. Yester­day Senator Taft announced that heunderstood that the Association of Amer­ican Medical Colleges would rather havethe bill defeated than passed with theamendment adopted by the Senate's Com­mitte on Labor and Public Welfare. Healso said that he would vote against thebill whether or not the amendment wasadopted. This is a most important questionto this nation. We who legislate for the na­tion have a right to honest, sincere, truth­ful advice from those citizens who inti­mately know the subject before us. Wecannot and should not have to expectdouble-dealing, dOUble-talking, or refusalsto answer on the part of such citizens.Therefore, and because I think the deansof our medical schools can be relied onto properly advise their government andbecause a very prompt answer is essen­tial tb the legislative process of yourgovernment, will you please reply to thiswire immediately. .

Representatives of the Association ofAmerican Medical Colleges and indi-

62ND ANNuAL MEETING

vidual deans, of which you were one,testified to a committee of the Senate thatour medical schools were in dire needof financial assistance; that they couldnot maintain the quality of their instruc­tion without such assistance. They toldus that $500 of federal money for eachenrolled student would materially aid insolving this "ciritical financial problem."This was the burden of your testimony.

Now keep this next fact in mind. S. 337with or without-I repeat, with orwithout any amendment-offers yourschool some financial assistance in meet­ing what you testified to be a most seriousproblem. The unamended bill offers $500per student currently enrolled. Theamended bill would offer, not the $500you would like but at least $200 for eachstudent currently enrolled. Either offerwould obviously help, at least in part andwith no strings attached, what you saidwas a serious financial problem-and,if it is serious, any help is a help.

Now another point to keep in mindbefore you answer my question, the $200per student which the amended bill wouldoffer is offered unconditionally. No schoolwould have to take in one single addi­tional student to get some of the financialaid which you told a Senate committeethe schools need. If a school wanted toexpand by taking in one or two or 10 or20 additional students with the federalgovernment paying $220o-almost its en­tire cost for so expanding-it could. Thedecision, however, is entirely up to theschool. If it decided not to, it still getssome of the financial aid which yourAssociation said the schools must have­at least $200 per stUdent and perhapsmore if the House of Representativesagrees with you as to the amount theschools both need and should get fromfederal funds. Now one last point I mustask you to keep in mind before I ask myquestion.

Some deans have said that the incentivepayment offered by the amended billmight lead some schools-never theirown, always some other schools-to lowertheir standards. I would remind you thatto prevent any such possibility the billprovides: first, that incentive paymentscan be made up to but not to exceed a30 per cent increase in enrOllment; second,that federal contributions cannot exceed50 per cent of any school's total costs;and finally and most important, that notone penny of federal money will go to anyschool which is not accredited by a rec­ognized accrediting body. You know and

59

ao<.l:1

I know and the legislative history of thisbill shows that the only recognized ac­crediting body as regards medical schoolsis the American Medical Association.This means no school could lower itsstandards below accepted standards inorder to take undue advantage of theincentive payments without the approvalof the A.M.A. If it should, your Councilon Medical Education need only withdrawaccreditation to stop its receipt of anyfederal funds.

Keeping these points in mind, remem­bering your testimony to your govern­ment as to the critical need of medicalschools for funds, and remembering thedeans' testimony that our bill is so drawnas to preclude any possibility of federalintervention with your affairs, pleaseanswer this question: would you ratherhave this bill killed than have it passedwith the committee amendment? If youranswer is Yes, will you please give meyour reasons in the light of the pointsset forth above. The Senate of the UnitedStates will vote on this important meas­ure this afternoon. May I ask that as aresponsive citizen you reply immediately.

JAMES E. MURRAY, Chairman,Committee on Labor and Public Welfare

3. Telegram to Senator MurrayOctober 4, 1951

Before your telegram arrived I hadlearned from Washington by telephonethat the Senate had killed the Pastoreamendment (the compromised Russell­Kerr amendment) to S. 337 early thisafternoon, and had then recommitted thebill to committee by voice vote. Of courseI am happy nevertheless to answer yourquestion: why did I withdraw my sup­port from S. 337 with the Pastore amend­ment?

I deeply regret feeling forced to with­draw my support because of the PastoreAmendment. As you know so well, Ihave worked energetically for monthsfor the passage of S. 337 in its un­amended form; i.e., as printed on January11, 1951. The original S. 337 provided$500 for each medical student currentlyenrolled and an additional $500 for eachmedical student enrolled in excess of theaverage past enrollment. This went along way toward providing the financialhelp so much needed by the going enter­prise of medical education. It providedalso a reasonable inducement for expan­sion. The Pastore amendment, $200 andan additional $2,000, puts an unreasonableemphasis on expansion while simultane-

60

ously jeopardizing the going enterprise.Two hundred dollars is completely in­

adequate. A drowning man will grasp atany straw. Hardpressed schools might notbe able to resist the eleven-to-one incen­tive for overexpansion even at the graverisk of reducing the quality of medical in­struction. The health and welfare of ourcitizens rest on the services of well­trained physicians. Only well-trainedphYsicians can give it. The Pastoreamendment stresses quantity at the ex­pense of quality. Therefore, I preferredto see S. 337, with the Pastore amend­ment, killed rather than passed. Theneed of the medical schools for S. 337without the Pastore amendment is asdesperate as ever. Hence I hope that thebill will be reintroduced promptly with­out the Pastore amendment.

GEORGE PACKER BERRY, M.D.,Chairman 9f the Committee on Finan­cial Aid to Medical Education of theAssociation of American MedicalColleges.

4. letter to Senator MurrayOctober 8, 1951

Dear Senator Murray:The present letter is written to amplify

my telegraphic answer (copy enclosed)to your telegram of October 4, and toexplain more definitively my objections tothe Pastore amendment, the modifiedRussell-Kerr proposals. Since I had al­ready stated why the Russell-Kerr pro­posals made the bill unacceptable, yourtelegram came as a great surprise.

May I say to clear your mind of anypossible doubts that I am as strongly infavor of S. 337-without the Pastoreamendment-as I was when I testifiedbefore your committee. As printed onJanuary 11, 1951, S. 337 is a constructive-indeed, a very necessary-piece of leg­islation. With the Pastore amendment,S. 337 loses its value, in my opinion, as aforce for good in medical education andbecomes a dangerous experiment, rootedin a philosophy that the compelling needin medical education today is quantityrather than quality. In fact, S. 337 withthe Pastore amendment is an entirelydifferent bill from the unamended version,the two bearin~ only a superficial rela­tionship to each other. The amendmentis so seductive that it opens the real pos­sibility that we shall convert strugglingmedical schools which are fightinit tomaintain their standards into diplomamills because in this direction would liepresumed immediate financial security.

~UTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

I think, then, we are clear on this point:I am strongly in favor of the original S.337. I am strongly opposed to it with thePastore amendment or any equivalentamendment which might create a situa­tion reminiscent of the days before 1910When, in many areas of medical education,quality was a secondary considerationin many schools.

The desperate need in medical educa­tion today is for "hard money" which canbe invested in the teaching program inorder that schools can maintain the teach­ing standards which have soared so highin the last 50 years. There are about 15per cent too few teachers in the medicalschools today due mainly to the inabilityof the schools to budget for these neces­sary positions. This is a dangerous situa­tion and if it continues, the health stan­dards of the American people and thedefense effort will suffer. But one cannotcure this situation by offering the med­ical schools large sums of money to ex­pand at a time when they are strugglinghard simply to keep their present teachingprograms abreast of scientific advancesin medicine and to maintain a reasonablestudent-teacher ratio.

It seems to me that the Pastore amend­ment has the cart before the horse, or,if I may be permitted to mix this meta­phor slightly, the Pastore amendment isequivalent to urging a half-starved horseto run faster. What the half-starvedhorse (the medical school) needs first isa good meal. Is it not folly to expect themedical schools, already struggling undertheir present burden, to expand andthereby increase the burden? I realize,of course, that no medical school is forcedto take the extra money, but on abasisof $2,200 per new student, the temptationof immediate gain is great and to theextent that such a temptation exists, theteaching program is in jeopardy.

The Pastore amendment, therefore, in­stead of solving a problem, creates one.

Let me say all this a~ain in anotherway: this amendment assumes that byincreasing the number of medical stu­dents, the teaching problem in medicaleducation will be solved. Yet the problemat the moment is finding money forenough teachers to handle the presentteaching program and insuring that theseteachers are adequately paid for theirservices. Adding more students will notsimplify the matter-even at $2,200 perstudent-it will only complicate it.

As a matter of fact, there is a funda­mental point of confusion in this ques-

62ND ANNUAL MEETING

tion that I think we should try tostraighten out. It is this: the quality ofteaching and the number of studentstaught are two different matters. Themedical school deans have supported S.337 because it represents an effort tomaintain quality and, in some areas, toimprove quality. The question of quantity-the number of students to be taught­is quite a different matter. To the best ofour financial ability to do so, we areadding students as rapidly as possible toour schools. As you know, far more thanmoney is involved in expansion-trainingadequate teachers, for example. We donot want, however, the educational struc­ture skewed so badly out of shape thatthe larger classes will suffer for lack ofcompetent and extensive enough instruc­tion. To do so, would do harm ratherthan good to the health of the nation.

What we would like to do, then, ismake more secure our present educa­tional structure, improving it where pos­sible, and offering the best possible educa­tion to as many students as we can affordto admit. Having achieved this, we cancontinue to expand as the situation per­mits, but never at the expense of quality.The Pastore amendment offers too littletoward quality, too much toward quantity.It is a foolish amendment, poorly thoughtout, in my opinion, and by no means a"compromise." An amendment as drasticas this does more than compromise: itchanges the basic philosophy of the bill.

May I say again that I hope S. 337 willbe reintroduced without the Pastoreamendment, or an equivalent. I hope youwill continue your greatly appreciatedefforts to further passage of this bill. Ishall continue to give you all the as­sistance I can in presenting the facts ofmedical education before the Senate.

Very truly yours,GEORGE PACKER BERRY, M.D.Chairman, Committee on FinancialAid to Medical Education, .Association of American MedicalColleges

5. Letter to Senator TaftOctober 8, 1951

Dear Senator Taft:The Pastore amendment to S. 337 was

so ill-advised, so poorly thought out andso changed the philosophy of the bill inmy opinion, that it was far wiser to defeatthe measure than to pass it as amended.This is what I told you last week duringtelephone conversations with Mr. Snead.I am writing the present letter to amplifymy statements.

61

ao<.l:11::(1)

a8o

Q

I urged defeat of S. 337 with the Pas­tore amendment with a great deal ofreluctance, for I have fought long andhard for a bill such as S. 337 and theresponse of senators to my queries wassuch that I expected the bill to pass.

Lest my withdrawal of support for theamended S. 337 create any confusion, Iam writing this letter to inform you thatI am still very much in favor of theoriginal, unamended bill. I hope it willbe reintroduced and that you will votefor it. I hope also that you and othersenators will oppose amendments of anature that will nullify the constructivefeatures of S. 337 as printed January 11,1951.

The Pastore amendment was a poorone because it placed the emphasis in thewrong direction. The problem at handis not primarily one of quantity. True,we need more doctors, but even so thefirst problem is one of quality. We mustmaintain our standards, improve themwhere we can. There are about 15 percent too few teachers in the medicalschools and unless this situation is reme­died, America's health and the defenseeffort will suffer regardless of the numberof M.D. degrees awarded each year. Theshortage of teachers is brought about bymany complicated factors, but one im­portant reason is the inability of theschools to budget for necessary teachingpositions. We must correct this conditionbefore we jeopardize the entire medicalteaching program. S. 337 was a good bill,aimed at helping us through this problemfor a limited period. EventUally we hopeto be able to solve this problem withoutcalling on Congress, but at the momentwe cannot marshal the necessary fundsthrough private channels.

The Pastore amendment provided $200per student, which is not nearly enough,and $2,200 for each new student, whichis much too much. It is such a seductiveoffer, such an appeal to quantity, thatour educational standards would be injeopardy. This amendment does not helpsolve our current problem; rather, itcreates a new and dangerous one, open­ing the possibility that some administra­tors may foolishly think their salvationlies in expansion. First, we must fortifyour present program, making it as finan­cially stable as possible, and then, ascircumstances permit, we can expand withthe expanding needs of the nation. Toexpand too rapidly might precipitate adisaster in medical education, returningus to the days before 1910 when standards

62

in schools in many areas were very low.Another important point: there is a

limit to federal funds. To use up sucha disproportionally large part of poten­tially available resources for expansionat the risk of quality would be a seriousmistake.

Let me say again, then, that althoughI opposed S. 337 with the Pastore amend­ment or any similar amendment whichplaces quantity above quality, I amstrongly in favor of S. 337 as it cameinto shape originally. It is a sound billand a very necessary bill, in my opinion.I hope that you will support it.

Very truly yours,GEORGE PACKER BERRY, M.D.Dean

AcceptanceThe annual report of the committee, in­

cluding the appendix was accepted with­out revision at the Business Meeting,Tuesday, October 30. A special vote ofthanks was given to the committee for thework performed.

Committee on VeteransAdministration-Medical SchoolRelationships

R. HUGH WOOD, chairman: At the paneldiscussion on veterans affairs held at theannual meeting of the Association ofAmerican Medical Colleges in October1950, a resolution was passed requestingthat the Association appoint a Commit­tee on Veterans Administration-MedicalSchool Relationships. In December of1950 announcement was made from theoffice of the A.A.M.C of the formation ofthis committee.

Before the committee had its first meet­ing, a matter of major importance cameto its attention when a crisis was pre­cipitated in the Veterans Administrationhospital program with the "resignation"on January 14, 1950, of the chief medicaldirector, Dr. Paul B. Magnuson. In orderto consider all aspects of the unsatisfac­tory conditions in the VA policy andprogram, culminating in Dr. Magnuson'sdismissal, the committee wrote to allchairmen of deans committees in thenation, asking for an expression ofopinion. Some 50 replies were received.All but one of these letters expressedgrave concern for the future of the med­ical program of the VA which had beenestablished under General Bradley andDr. Hawley. Because of the prevailingfeeling of apprehension, deans of all med­ical schools affiliated with a Veterans

ndINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

Administration hospital were invited toconsider the matter at a meeting in thePalmer House in Chicago, Sunday, Feb­ruary 11, 1951, during the A.M.A. Con­gress on Medical Education and Licensure.

The Committee on Veterans Adminis­tration-Medical School Relationships wasinvited to attend a meeting of the Execu­tive Council on February 9, 1951, at whichthe administrator of veterans affairs,Gen. Carl A. Gray Jr., and Dr. Paul B.Magnuson appeared. The points at issuewere of such importance that the Execu­tive Council, in combination with theCommittee on VA Relationships, jointlyconsidered the matter during the next24 hours. The committee report, therefore,is combined with the statement made bythe Executive Council of the Associationon the date of February 12, 1951, a copyof which is attached hereto.

There were 41 medical schools repre­sented in the meeting at the PalmerHouse, Sunday, February 11, 1951. Allpresent expressed universal feelings ofapprehension and concern for the futurewelfare of the VA program because of theincreasing difficulties with administrativematters bearing directly upon the pro­fessional care of patients. Many incidentsoccurring in different hospitals over aperiod of two years which adversely af­fected the medical care of the veteranpatient and which made Dr. Magnuson'sdismissal even more significant werebrought out in this meeting. The groupvoted unanimously to request theA.A.M.C. to take prompt action to seethat sufficient autonomy and authoritybe given the Department of Medicine andSurgery to insure that the veteran pa­tient would continue to receive the highestquality of medical care.

At the request of Sen. Hubert Hum­phrey, Dr. Joseph C. Hinsey, Dr. John B.Truslow and Dr. R. Hugh Wood ap­peared before the Senate Subcommitteeof the Committee on Labor and PublicWelfare which was investigating themedical program of the Veterans Ad­ministration on February 20, 1951. Thestatement of the Executive Council ofFebruary 12 was read by Dr. Hinsey,following which Dr. Truslow and Dr.Wood cited difficulties stemming fromthe cumbersome organization of the VAand the arbitrary attitude and policy ofcertain administrators.

At the completion of the hearings ofthis subcommittee, it made public itsreport and recommendations on July 11,1951. This report was quite satisfactory

62ND ANNUAL MEETING

in its general tone and attitude towardthe necessary changes in VA organiza­tion and policy in order to insure a highquality of medical care. The followingfive recommendations to be accomplishedby and within the VA are significant:

(1) The VA administrator shouldformally delegate to the chief medicaldirector such primary authority as maybe necessary to insure his effective con­trol over all policy affecting the care andtreatment of patients and over the man­agement and operation of the hospitalsystem, and this delegation of authorityshould be clearly and unequivocably setforth.

(2) No one shall be appointed managerof a VA hospital without the prior ap­proval of the chief medical director.

(3) All special services personnel andactivities in VA hospitals must be underdirect control of hospital managers andoperate only in accordance with policiesapproved by the Department of Medicineand Surgery; furthermore, considerationshould be given to abolishing the officeof assistant administrator for specialservices, not now under the control ofthe medical director.

(4) Budgetary control proceduresshould be revised, with a view to makingthe hospital manager responsible for asingle budget.

(5) Personnel ceiling procedures shouldbe revised to give the chief medicaldirector more flexibility in the allocationof personnel to hospitals.

In addition there were three recom­mendations for changes in the legislationpertaining to the VA, to be enacted byCongress. They are:

(1) Public Law 293 (79th Congress)should be amended so as to leave nodoubt whatever that the Congress intendsthe chief medical director to be theprincipal medical authority of the agencywith primary authority to control, manageand operate its medical and hospitalprogram.

(2) The law (38 U.S.C. 15) should beamended to provide that the chief med­ical director be appointed by the Presi­dent with Senate contlrmation.

(3) Functions of the special medicaladvisory group to VA (established byP.L. 293, 79th Congress) shOUld be re­aligned to provide for (a) changing thename of the group to the Advisory Com­mission on Veterans' Medical Care, (b)appointment of commission members bythe President, (c) representation on thecommission of the public, veterans and

63

ao<.l:11::(1)

a8o

Q

"eminent authorities in the respectivehealth professions," including membersof the deans'. committees, (d) continuingreview by the commission of VA's med­ical and hospital program, with a reportat least annually to the administrator andthe chief medical director, and (e) regu­lar reports to Congress by the administra­tor on the commission's recommendationsand his action with respect to them.

This report of the Senate subcommitteefurther stated that these recommenda­tions were read in the presence of theadministrator and the chief medical di­rector of the VA, and that they agreedwith the principles and implications ofthese recommendations.

The chairman of the committee had theopportunity to ask Admiral Boone onOctober 5, "What has the VA done tocarry out the five recommendations madeby the SUbcommittee of the SenateLabor and Welfare Committee?" AdmiralBoone replied that the administrator haddeemed it wise to wait until the reportof the management survey now in prog­ress by Booz, Allen and Hamilton hadbeen complete. In quoting General Gray,Admiral Boone expressed the feeling thatif changes in reorganization were madenow, it might result in confusion becauseof additional changes or even conflictingchanges that might be recommended bythis management survey.

Dr. Robert S. McCleery of Nashville,Tenn., for himself and representing acommittee of citizens in Nashville, hasvisited many of the medical schools andall the members of the Executive Councilof the Association of American MedicalColleges. He is concerned, as are manyother citizens, with the problem of abuseof the privilege of nonservice-connectedveteran patient, who may now be ad­mitted to the VA hospitals on his ownsworn statement that "in his opinion"he is unable to pay for the necessaryservices. Upon the request of the chair­man of the Executive Council, Dr. Woodand Dr. McCleery visited Admiral Booneon October 5, 1951.

A conference with Admiral Boone andJudge E. E. Odom, the solicitor of theVA, was held and all points at issuewere fully discussed. It was pointed outthat the VA operates under what isknown as permissive legislation. This Isin contradistinction to the legislationunder which the armed services andother federal agencies operate and meansthat the VA may do nothing except whatis expressly permitted by law, whereas

64

the armed services may do anything ex­cept those things which are expresslyprohibited by law. Therefore. the Vet­erans Administration is not able to en­force penalties provided for fraud, norare they able to investigate the financialstatus of VA patients. However, themanagers of the hospitals are permittedto report obvious instances of fraud, anddirectives from central office have beenissued to this effect.

The solicitor was asked, "Are instancesof fraud reported to central office, andif so, what has been done about it?"Judge Odom replied that in past years,following the legislation passed in 1935,instances of fraud were reported regularlyby the hospitals to central office. If thecase seemed clearcut and the evidencesufficient, these cases were referred to ­the Department of Justice for prosecu­tion. Many cases were brought to trialby the Department of Justice, but not oneconviction of a veteran patient has everbeen secured. The Department of Justice,therefore, has stopped trial of cases itcould not win; central office has ceasedto refer them to the department; andfinally the managers have ceased to re­port them to the central office. In thisway, enforcement of the law has brokendown all along the line.

A full statement of public law govern­ing the operation of the Veterans Ad­ministration and VA directives pertainingto policy and procedure dealing with thenonservice-connected VA patient who isable to pay for medical care was prom­ised the chairman of the committee butdid not arrive in time for inclusion withthis report.

Dr. Robert McCleery posed the fol­lowing questions which he hoped AdmiralBoone would be able to answer at thismeeting of the Association in FrenchLick. They are: (1) Where in the PublicLaw governing the operation of the VAis the prohibition against later investiga­tion of the sworn statement on FormP-10, which the veteran signs upon ad­mission to a VA hospital, and by whichhe declares that he is unable to pay forthe medical care he needs? (2) Where inthe Public Law may be found the author­ity for accepting a veteran with a non­service-connected disease or injury fortreatment in a VA hospital, who at thesame time possesses a private insurancehospital policy which would pay his hos­pital and physician fees? These questionsalso were not answered in time for in­clusion this report. It is hoped that Ad-

~UTES OF THE PROCEED~GS

ao<.l:11::(1)

a8o

Q

miral Boone will be able to throw somelight on these matters when he appearsbefore the Executive Council.

The only further matter which hascome to the attention of this committeehas been a statement directed to Dr.Hinsey by Dr. Robert B. Aird, chairmanof the combined dean's committees ofthe Veterans AdministratIon Hospital,San Francisco, Calif. He addressed thefollowing complaints to Dr. Hinsey, whoin turn referred them to the chairmanof the committee. • n his communication,Dr. Aird called attention to the fact thatsweeping changes in budget, policy andprocedure have been made by centraloffice of the VA without prior consultationwith the deans committee and that theposition of the deans committees of hisinstitutions was made untenable by thesechanges. Correspondence is included,dating from April 12, 1950, in whichthese matters were called to the atten­tion of the administrator and the chiefmedical director. The request was madethat these matters should be consideredat the next meeting of the A.A.M.C., thefeeling being that these difficulties areof the same nature as those experiencedby other deans committees and thereforecause for concerted action by the A.A.M.C.

The Committee on Veterans Adminis­tration-Medical School Relationships rec­ommends that the A.A.M.C. officially con­sider the items set forth in this reportand that specific action be taken on thefollowing points:

(1) The VA should be requested toassure the medical schools that it isprepared to put into effect the five rec­ommendations of the Senate Subcommit­tee.

(2) The A.A.M.C. must be assured bythe VA that it is in agreement with therecommendations of the Senate Subcom­mittee as quoted in this report.

(3) This committee recommends thatconsideration be given to the desirabilityof amending the federal law in such away that the relationships of medicalschools to the VA be so organized as totake the form of a contract.

(4) The abuse of the privileges ofhospitalization by veteran patients withnonservice-connected disabilities who areable to pay for the cost of adequatemedical care, is reported to be wide­spread. Accordingly, the committee rec­ommends:

(a) That each medical school, throughits dean's committee, ascertain the extentto which such a practice might endanger

62ND ANNUAL MEETING

the present high quality of medical serv­ice being given in its affiliated VeteransAdministration hospital or hospitals.

(b) That each medical school takesuch steps as may be seen to be appro­priate to protect the present programsof medical education and care; and

(c) That the Association of AmericanMedical Colleges ask the Veterans Ad­ministration for a full statement of alllaws, directives and policies pertaining tothe admission of veteran patients in thiscategory.Acceptance

The annual report of the committee wasaccepted at the Business Meeting, Tues­day, October 30, after the final paragraphswere revised to read as above.

Committee on Foreign StudentsFRANCIS SCOTT SmYTH, chairman: Be­

cause of the ever-increasing number ofrequests from foreign doctors for furthertraining in the United States, the Com­mittee on Foreign Graduate Students wasformulated to handle this activity. Thecommittee has been functioning underthe chairmanship of Dr. Francis ScottSmyth since December 1950. An interimreport of committee activity was given inFebruary 1951. The committee has nowreached the point of being an importantdistributing instrument of the Fulbrightand E.C.A. programs through the StateDepartment's Committee of Exchange ofPersons and/or its varidus subsidiaryagencies.

The Exchange Program: To brieflyreview: on August 1, 1946, Congress en­acted a bill which has come to be knownas the Fulbright Act, which authorizedthe Secretary of State to use foreigncurrencies which were not convertibleinto dollars to finance Americans study­ing abroad and to help bring foreignstudents into the United States. Theforeign currencies came from the sale ofsurplus war materials left in foreigncountries at the conclusion of World WarII, and were scattered throughout Europe,Asia and the Near East. With the enact­ment of the legislation by the Congresscame institution of the program for theexchange of students, which met withimmediate favorable reaction among aUthe people of the free world.

This committee is not concerned withAmericans who go abroad to study. Ourwork confines itself solely to those foreigngraduate doctors who come here forfurther training in order to return to

65

ao<.l:1

their native lands to teach. It has takentime for students to learn that since agrant is made in their own currenciesinstead of American dollars, it can beused only to pay their way to Americanshores. To cover their maintenance whilehere they must have either a scholarshipfrom a university, private help or anotherU. S. government dollar grant (madeavailable under the Smith-Mundt Act).

Figures up to June 30 of this year(quoted by J. William Fulbright in NewYork Times article, August 5, 1951) in­dicate the equivalent of approximately$11,500,000 in foreign currencies, not re­payable in dollars, has been paid byforeign countries for benefits to 7,393Fulbright grantees. Of these 3,181 wereAmericans who had gone abroad to study,teach, lecture or conduct research, while3,234 citizens of other countries have re­ceived awards for similar· studying inAmerican institutions in foreign countries.

In addition to Fulbright scholars, weare also now handling a constantly in­creasing number of participants underE.C.A. sponsorship.

Committee Share in This Exchange:The liberal arts are favored by Americansstudying abroad, while their counterpartsfrom other lands show a preference formedicine and engineering which will pro­vide them with skills and techniquesurgently needed in their countries.

Our own committee has worked inclose cooperation with the ConferenceBoard of Associated Research Councilsof the Committee on International Ex­change of Persons and with the Instituteof International Education, as well asvarious other agencies of the government(Public Health, Federal Security Agency,E.C.A.) through their individual programsunder which visitors have come for ex­tended visits.

It is worthy of mention that once adoctor arrives for a period of training, heremains within the division under thedirection of his chief for the stipulatedperiod, while a visitor-whether for along or short period-requires facilities,introductions and much detailed planningto achieve the greatest results from hisstay.

Out of a total of 255 applications sub­mitted through the governmental agen­cies, the A.A.M.C. schools placed 168doctors (our own schools having placed25 of these). .

The office of the committee chairmanhandled a total of 80 candidates, eitheras visitors or grantees, representing 29

66

different countries. Whatever the cate­gory, the problems placed before u.s were,for the most part, those requiring longrange consideration. Brief examples are:

Books: The shipment of medical booksand literature to the Philippines and theOrient, to supplement depleted libraries,has been most effectively handled by theArmy transport through the able help ofMrs. Carter Collins of the Army Wives'Association. With the signing of the peacetreaty with Japan, however, we are tryingto ascertain how far tflis help will extendand continue in these official channels,and without cost to the Association ofAmerican Medical Colleges.

Problems: (1) Understaffing fn AsiaticMedical Colleges: This is a problemwhich has come to us through many chan­nels: whether medical schools-like thatof Taegu in Korea-should recall the menwho have been training in the UnitedStates in order to meet the dire need forpractitioners in those countries or permitthese men to remain for completion ofthe work which they had set out to do.The Presbyterian Board of Foreign Mis­sions, and especially Harould Loucks ofthe China Medical Board have offeredmuch in the way of constructive help andsuggestions in this field.

Visitors from Korea, Burma and Indo­nesia, correspondence from India, as wellas the current situation all point to thegrave problem in this perimeter of theglobe as to the type of training whichshould be instituted in the medicalschools for the best long range resultwithin these lands. Discussions and cor­respondence with agencies and boardsproduce conflicting theories. Delegationsof specialists for a limited period areurged by some as being the answer to aquick solution for producing native teach­ers: others favor a combination of delega­tions for an extended period of time toteach the basic sciences and to set up themost efficient working standards to meetthe needs of the particular land for whichdoctors are being trained. This programis to be supplemented, in any case, byfaculty or potential faculty coming to theUnited States for postgraduate training.Consideration of these factors is importantand necessary, and thought should begiven it by the Committee on ForeignGraduate Students.

(2) Ultimate Aims for Health andWelfare of Populations: In areas of densepopulations with few schools of medicineand proportionately few doctors, this aimcannot be achieved by education of only

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

a select number of doctors. Somethingmore is required to meet the generalhealth and welfare needs of these people.Mass education of the people is desirableand can be more rapidly accomplished ifless orthodox techniques (such as thoseused by Jimmy Yen in China for lan­guage) are applied as fits the native situ­ation, rather than those techniques fixedand orthodox for the occidental areas.

Historically, the physician is both ateacher and therapist. The healing art forthe individual patient and the dispensingof drugs pJ;ecedes the realization thatprevention of disease, sanitation, andnutrition are ultimately the goal of thehealth sciences. It would thus seem de­sirable in regard to the role of medicaleducation in certain areas to emphasizethe participation of the faculties andphysicians in programs by which theeducation in prevention, sanitation andnutrition can be more quickly acquiredby the population. While in our countrythis is the role of the public health pro­fessionals, it would seem unlikely thatthe ordinary school of public health isthe entire answer. Rather, it suggests theneed of widespread participation of na­tives in short training schools, not somuch as therapists but as preventivehealth agents. Without specialized edu­cation requirements, elaborate laborato­ries or great technical facility selectedyoung people could be trained in therudiments of midwifery, contagion pre­vention, sanitation and nutrition in sixto l2-week periods. It would be of bene­fit to all to hear Dr. Leo Eloesser discusshis active experience in this field in hiswork with the World Health Organization.

Future Activity of the Committee: Withthe expanding participation of the com­mittee in the international picture, therenow arises the responsibility of consider­ing the next logical step which may arisein our dealings with the State Depart­ment through its authorized agencies.With large appropriations to be madeavailable for technical and medical edu­cation of the countries coming under theEconomic Cooperation Administration'sprogram in designated countries, we arebound to be faced with the acceptance ofthe challenge and determining the formwhich our assistance is to take.

Recent trends in policy have focusedthe attention of the committee chairmanto the E.C.A. program in Southeast Asia,with special consideration of Indonesia.The problem in these countries is notprimarily lack of money to pay for needed

62ND ANNUAL MEETING

imports but, rather, the lack of technicalequipment and skill to carry forward thenecessary programs of reconstruction, re­habilitation and development. Medicalschools in these countries are faced sud­denly with the problem of educating thegreatest number of doctors in the shortestspan of time. The only possible sourceof additional faculty for training theirfuture doctors would be provided by theconsideration of the A.A.M.C., and theextent to which they can assist thesecountries in meeting this demand. This is,of course, in addition to permitting aselect few to come to the United Statesfor further training and again returningto their native land to teach.

It is the view of the chairman of thiscommittee that the Association of Ameri­can Medical Colleges, through its Com­mittee on Foreign Graduate Students, hashonestly and intelligently cooperated notonly with the State Department of theUnited States in its primary aim of aidinginternational understanding, but also tothe men who have sought and come to ourland to further the basic aims of extend­ing medical education.Acceptance

The annual report of the Committee onForeign Students was accepted withoutrevision at the Business Meeting, Tues­day, October 30.Addltlonal Reports

As a part of the report of the Commit­tee on Foreign StUdents, the followingreports were made by Dr. Howard Klineof the U. S. Public Health Service, andby Dr. Robert Moore of WashingtonUniversity:

DR. KLINE: As part of the overall pro­gram of both the Department of Stateand of ECA, to assist in the technical de­velopment and the economic developmentof certain underdeveloped countries, thePublic Health Service has urged theDepartment of State and ECA to investpart of its effort in moves to improveboth the health and the medical facilitiesto meet the medical needs of the peopleof these underdeveloped countries. Wewish to assist them to meet their needsquantitatively and work for the improve­ment of the medical" personnel beingtrained in their several countries. In thematter of quality, we urged both ECAand the Department of State, and so faronly ECA has gone its way to do this.The Department of State may well follow.We have urged them to turn to the med­ical schools, student nursing schools,schools of public health, and other re-

67

ao<.l:11::(1)

a8o

Q

lated institutions, and appeal to them andmake available appropriate finances tosend abroad visiting United States pro­fessors to teach in their institutions.

We may ask these professors to specifythe limited amount of additional suppliesand equipment which will be necessary tosubstantially improve their teaching, andto receive in this country and train desig­nated nationals, particularly teachers fromtheir training institutions to be receivedhere for further training. There are spe­cific affiliations at this time between Wash­ington University Medical School at St.Louis and Chulakankarana University inBangkok in Thailand. Preliminary discus­sions are going on and have been goingon, and I understand negotiations are invarious stages with the medical schools ofColumbia University, University of Cali­fornia, University of Pennsylvania andJohns Hopkins involving potential rela­tionships with the Medical SChool of For­mosa, the University of Indonesia Medical,the Medical School of Rangoon in Ran­goon, Burma, and the University of thePhilippines Faculty of Medicine.

I would like to take this occasion onbehalf of the Public Health Service andother government agencies and privatefoundations as well to pay special tributeto the splendid and understanding man­ner in which the members of this Asso­ciation have received and guided numer­ous and bewildered foreign fellows who 'have come to. your institutions seekingthe higher training which we are so emi­nently able to provide in this country.

DR. MOORE: At the last meeting of theAssociation, you will recall Dr. Malmbergpresented this matter which Dr. Kline hasdiscussed. For reasons which I need notgive you now in detail but will be gladto tell you if there is any reason for it,the relationship between Washington Uni­versity School of Medicine and the med­ical schools in Bangkok, Thailand, seemeda natural one because of past events.Therefore, early in November, we offeredto negotiate with the Economic Coopera­tion Administration looking toward a con­tact. After four months of negotiations,one month of seriousness of principles,and three months of haggling over detailswhich seemed to us important in an aca­demic venture with a comptroller andlawyer and travel expert who had nopervious experience with universities andacademic matters, we signed a contractwith ECA.

The essential facts of this contract are,of course, that it runs for a two-year pe-

68

riod, that we undertake to assist in thedevelopment of medical and nursing edu­cation in the two medical schools affili­ated with the University of Thailand, theSerrot and the Chulakankarana MedicalSchool. We do not undertake any respon­sibility for medical service in Thailand.This is a program of education and notof service. It is looking toward medicalservice in the future, not medicl:11 im­provement. That contract calls for a grantof funds from Washington Universityalong the general lines of other contractswith universities and government. Wash­ington University handles the funds fortwo general purposes: first, a smallamount for administrative expenses in theUnited States to carryon this program;second, to pay the salaries of the mem­bers of our faculty who go to Thailand.Those salaries are paid in dollars. We ac­cept no administrative responsibility forthe medical schools in Thailand. We arethere to assist and help, and not to runthe medical schools. There is no sense ofimperialism in our concept or in our con­tract.

We agree to have not less than sixfaculty members in residence in Bangkokduring the year. We agreed to take what­ever number can be reasonably accommo­dated in St. Louis from their faculty. Theselection of those men who come to St.Louis is in the hands of the Ministry ofMedical Education of the Government ofThailand with our approval of the candi­date and ECA's approval after he is se­lected by them.

We are not taking men and trainingthem to be physicians. We are taking themto train them as future professors in thosemedical schools. Again the emphasis ison education and not the medical service.

At the moment, we have 14 people fromThailand in St. Louis and at the first ofthe year we will have 20. That is all wecan possibly take and distribute them be­tween the various departments of themedical school.

At the same time, ECA undertook tosend equipment to Thailand which wouldgive the medical school the equipment itneeded to do a good job. That equipmentlanded in Thailand in September of thisyear. I am sure you are interested in thefinancial remuneration of the men who goto Thailand. We have no responsibilityfor the Thai people who come to theUnited States. That is a problem for theThai government. We are responsible onlyfor the salaries of our people who go toThailand. Those men draw their Amer­ican salary plus 25 ner cent for overseas

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

duty. They are given a living allowan~e

of between $1000 and $1500 a year III

addition. If they stay for one year, theirentire expense and that of one dependentto and from Bangkok, which is aroundthe world-the air fare is within 50 centsin each direction-is paid for them, andif they stay 12 months, they get onemonth's vacation with full pay which theycan use wandering back to the UnitedStates.

We sent out nine people including abio-chemist, pathologist, pediatrician, sur­geon, operating nurse, hematologist andpathology technician. Seven were fromour own school and two we got fromother schools by those individuals get­ting sabbaticals from their schools. Twowere professors, three assistant professors,three were instructors and one was atechnician. Seven of them were to remainfor one year and two were to remain forthree months or less.

The advantages that we see are first,to the individual there is a professionalexperience which is tremendous. In path­ology, the individual will gain profession­al scientific experience he could never getany other place under any other circum­stances.

We are pleased with the program. Weare pleased that the administrator, theassistant dean of the school, went out andstayed two months while the thing gotstarted. He was the only American med­ical man who has ever been editorializedin the Bangkok newspapers when he leftafter a stay of two months.

We need some changes in our contract.We propose to take those up with ECAnext month. These changes are concernedlargely with administrative help in Bang­kok with some sort of health insurancefor the people who go out.

Now something about these Thai peo­ple wh~ come to St. Louis. When we bringscientific people to the United States, wegive them a superb scientific education,but there is something else we are afterin contracts of this sort, and that is tosell the democratic way of life, and whilethose people are in this country, we shouldtake advantage of that and sell them theWestern world. That can't be done in thelaboratory. It has to be done outside intheir relations with the community.

Finally, the reason we are in it and theadvantage we see in it: we believe thatany group of people who have good healthand have food in their stomach will notseek the new way of life, and we wantto keep the people of southwest Asia fromseeking a new way of life right now.

62ND ANNUAL MEETING

Committee on Internshipsand Residencies

JOHN B. YOUMANS, chairman: The workof the Committee on Internships and Res­idencies during the past year was con­cerned principally with (1) the operationof the Cooperative Plan for the Appoint­ment of Interns, and (2) with the devel­opment of changes in that plan.

For the internship year 1951-52 certainchanges were again made in the plancompared with the previous year. Thesechanges consisted, in part, of those rec­ommended following a study of the planat a conference of the various interestedagencies in Chicago on September 13,1950. Briefly, these provided for the si­multaneous filing of telegrams offeringappointments after 9 A.M., E.S.T., on thesecond Tuesday in February 1951, andthe release or delivety of the telegramsat, but not before 3 P.M., E.S.T., of thesame date. In addition they included forthe following year (intern year 1952-53)the provision that, "Hospitals and/or stu­dents shall not follow telegrams with tele­phone calls until after 9 A.M., E.S.T., (thefollowing day) except for acceptance ofan appointment by a student."

Paragraph 2 of the then existing planwas changed to read as follows:

"Application should be made in dupli­cate; the original to be forwarded to thedean of the applicant's medical school fortransmission, together with credentials tothe hospital or hospitals by the applicantas soon as he or she has filed the originalwith the dean any time prior to December19 (1950)."

It was also agreed that:"1. Deans will be advised to have stu­

dents furnish telegraph office with addressand phone numbers where they can bereached February 21.

"2. It will be suggested to the deansthat they have students concerned meetin some central place at the proper timeon February 21.

"3. That a conference will be held withthe Western Union officials at nationallevel but deans are advised to arrangewith Western Union at local level also.

"4. That a statement be made to theeffect that the plan applies only to grad­uates of the current year."

At the meeting of the A.A.M.C. atLake Placid these recommendations wereadopted with, however, certain modifIca­tions. The provision that "hospitals orstudents shall not follow telegrams of of­fers of appointment with telephone callsuntil after 9 A.M., E.S.T., (8 A.M., C.S.T.;

69

ao<.l:11::(1)

a8o

Q

7 A.M., M.S.T.; 6 'A.M., P.S.T.) February21, except for acceptance of an appoint­ment by a student," recommended for theintern year 1952-53 was made effectivefor the current intern year (1951-52).

The recommendation that machinematching be used on a voluntary and trialbasis was also approved.

These changes were announced and re­ported to the medical schools, to the hos­pital associations and hospitals, and toother interested agencies and persons bymeans of letters to the deans, notices inthe Journal of MEDICAL EDUCATION, theJournal of the American Hospital Asso­ciation and by many individual letters.Unfortunately the American Hospital As­sociation failed to approve the part of theplan concerning the use of the telephone,and this was communicated by mimeo­graph letter to all deans on February 1,1951, with the information that the Com­mittee on Internships and Residencies hadcarefully considered this situation and haddecided that it was inadvisable for theAssociation to attempt to enforce this pro­vision of the plan. Such actions as theymight wish to take were left up to theindividual deans. Suggestions were givenas to procedures which were to be fol­lowed locally.

As provided by the recommendations ofthe committee, approved by the Associa­tion, arrangements were made in advancewith national representatives of WesternUnion, and in this the offices of the Amer­ican Hospital Association were very help­ful. Instructions were issued to localWestern Union offices by the companyand copies were sent to the deans, to­gether with a copy of the statement sentto hospitals by the A.H.A., as a basis forperfecting local arrangements.

A temporary committee to operate themachine matching, with representativesfrom the various associations concerned,was appointed by the chairman of theCommittee on Internships and Residen­cies, as follows: Dr. Edwin L. Crosby,American Hospital Association; Dr. Ed­ward H. Leveroos, American Medical As­sociation Council on Medical Educationand Hospitals; Rev. Joseph A. George,American Protestant Hospital Association;Dr. Francis J. Mullin, Association ofAmerican Medical Colleges; Msgr. JohnBarrett, Catholic Hospital Association ofUnited S~ates and Canada; Col. RichardB. Jones, United States Air Force; Col.James G. Simmons Jr., United StatesArmy; Capt. R. H. Fletcher, United StatesNavy; Dr. Kenneth W. Chapman, Federal

70

Security Agency, U.S.P.H.S.; Dr. JamesT. Smith, Veterans AdIninistration.

Dr. Edwin L. Crosby, Dr. Edward H.Leveroos and Dr. F. J. Mullin wereelected as the Executive Committee, andJohn M. Stalnaker designated as directorof operations. The actual operation wasperformed at the office of the A.A.M.C.with facilities provided there. Costs werepaid by the Association by means of aspecial grant. Instructions were sent to allmedical schools and hospitals concernedand on April 13, 1951, all hospitals offer­ing internships were notified that the re­sult of the trial run of machine matchingwas being studied and would be reportedlater.

In actual operation the plan proceededmore smoothly than in previous years andon the. whole was very satisfactory. Inpart this was a result of greater prepara­tion and familiarity with the plan andto a considerable extent, I believe, to thechanges in the plan. On the other hand,there was a considerable number of com­plaints and objections to unfair practices.Paradoxically, this is believed to havebeen largely the result of more generaland more faithful participation in, andcompliance with, the plan. This focusedattention to a greater degree on the non­conformists and on those hospitals whichparticipated but failed to observe the reg­ulations. However, the operation of theplan emphasized and demonstrated morestrikingly than ever the problems and dif­ficulties caused by the great disparity be­tween the number of approved internshipsand the number of graduating students,and called attention to the lengths towhich some hospitals will go to secureinterns. No complaints were made fromstudents or medical schools. Communica­tions from some hospitals indicated a lackof knowledge of the nature of the plan(despite a very considerable amount ofpublicity and information). The generalfairness of the plan seems reflected in thefailure of a number of teaching and uni­versity hospitals to secure as many in­terns as they wished.

The machine matching, which was op­erated on a trial basis as approved by theAssociation at its meeting in October 1950,was generally very successful despite its"trial nature." Compliance and coopera­tion were very good and the results dem­onstrated clearly its value and practical­ity. A full report has been made to allmembers of the Association and to theothers concerned and will not be repeatedhere. Suffice to say the trial run justified

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

the adoption of the procedure on an offi­cial and permanent basis as will be dis­cussed below.

The success of the plan and, at the sametime, the problems and difficulties dis­closed by its operation, the result primar­ily of the great disparity between ap­proved internships places and the numberof graduates, served to direct attentionmore insistently than ever to the prob­lems of internships appointments.

The committee was fully, even pain­fully, aware of the problems and had an­nounced its intention to continue its studyof them. To this end an ad hoc sub­committee was appointed and met in Chi­cago on May 23, 1951. As reported to thefull Committee on Internships and Resi­dencies by letter dated June 8, the re­sults of the deliberations of the committeewere as follows:

It was apparent that we were facedwith several alternatives. (1) We couldattempt to secure the cooperation of theAmerican Medical Association's Councilon Medical Education and Hospitals inhaving them reclassify internships, reduc­ing the number, or joining us in doing so.(2) We could inspect and classify themourselves. (3) We could attempt to securebetter cooperation with the hospital asso­ciations in improving, strengthening andoperating the present plan. (4) Finally,we could give up the whole idea.

Both of the first and second possibilitiesseemed out of the question at the present.We were unwilling to adopt the lastcourse, although it was felt that unlesssome move was made to strengthen thepresent plan and put some penalties in it,the plan would die. We had heard fromDr. Mullin that the third choice might bepossible and practical, and that both thecouncil and the American Hospital Asso­ciation were somewhat disposed to co­operate in making the present plan moreeffective. It was therefore decided to awaitthe report and recommendations regardingfuture plans and procedures of the tem­porary subcommittee appointed to oper­ate the trial run of machine matching,which was to meet in Chicago on May 23,1951.

These were the result of long thoughtand careful deliberation by the repre­sentatives of the various associations andagencies vitally concerned with this prob­lem. Because of the complex and ex­ceedingly difficult nature of the problemthe recommendations represented certaincompromises but were believed to be avery distinct advance and a sound prac­tical working solution.

62ND ANNUAL MEETING

In the meantime, at the meeting of theAmerican Medical Association in AtlanticCity in June 1951, and while the tempo­rary committee on machine matching wasdeliberating the problem, the Council onMedical Education and Hospitals of theA.M.A. acted to set up a specified numberof internships for each hospital accreditedor approved for intern training. This ac­tion was reported to the members of theCommittee on Internships and Residenciesby letter from me on July 7, again onAugust 2. In reporting on the first meet­ing of the National Interassociation Com­mittee on Internships, further commentwas made on the action of the council ofthe A.M.A. in reducing the number of ap­proved internships. This action was laterrescinded as announced by the council.

As indicated above, the ad hoc NationalInterassociation Committee, after a studyof the results of the trial of the machinematching procedure, arrived at certainconclusions and made certain recommen­dations. These were as follows and werereported to the Committee on Internshipsand Residencies as well as to other in­terested agencies and persons:

1. That a permanent committee, to beknown as the National InterassociationCommittee on Internships, be establishedwith power to act on procedural mattersrelative to internship appointment. Thecommittee to be responsible to the con­stituent bodies of the American HospitalAssociation, American Medical Associa­tion Council on Medical Education andHospitals and the Association of AmericanMedical Colleges for approval of policymatters. The committee to be composedof the following 11 voting members:

One member designated by the Amer­ican Catholic Hospital Association; twomembers designated by the AmericanHospital Association; three members des­ignated by the American Medical As­sociation Council on Medical Educationand Hospitals; one member designatedby the American Protestant Hospital As­sociation; three members designated bythe Association of American Medical Col­leges; one member chosen by and fromthe five liaison members, representingthe Air Force, Army, Navy, Public HealthService and Veterans Administration);one non-rating liaison member to be des­ignated by each of following governmentservices concerned with internships: AirForce, Army, Navy, Public Health Service,Veterans Administration.

When a student organization is repre­sentative of a majority of the senior medi-

71

ao<.l:11::(1)

a8o

Q

cal students, consideration should be givento inviting it to designate a representativefor membership on the committee.

2. That the administrative responsi­bility for the operations of the appoint­ment procedures be carried out by theAssociation of American Medical Collegesunder regulations set by the NationalInterassociation Committee on Internships.

3. That for the appointment of internsto start their internships in July 1952, thematching plan, as conducted this year, befollowed as the official method.

4. That whereas the full cooperation ofstudents, hospitals and medical schools isessential for the successful operation ofproposed intern appointment plan, thefollowing steps be taken to assure effec­tive participation:

(a) All constituent organizations willadopt the plan officially and actively sup­port it.

(b) A separate list of hospitals parti­cipating in the plan will be publishedwith an indication that the plan is spon­sored and supported by the constituentorganizations. The A.M.A. council will berequested to publish, at the committee'sexpense, a directory of participating hos­pitals excerpted from its list of approvedhospitals, containing the necessary in­formation for the operation of the plan.

(c) Students and hospitals will be re­quired to sign a contractual obligationto abide by the results of the plan.

(d) The deans of medical schools willbe asked to use every effort to have theirstudents comply fully with the plan andto advise their students to apply only toparticipating hospitals.

(e) Appropriate disciplinary action willbe taken by the committee against stu­dents and hospitals which agree to parti­cipate, but which do not conform to theregulations.

(f) The committee as a whole will actas a review board in the case of com­plaints regarding conformity. If complaintsinvolve a government service, the liaisonmember of that service will be votingmember of the reviewing board.

5. That in order to proceed with theplan this year, ratification of the pro­posals and. the designation of representa­tives for committee membership by theboards or councils of the constituentgroups should be obtained in time for thenew committee to meet by July 1, 1951.

6. That the present National Interasso­ciation Committee serve until the new.committee has been formed.

72

7. That the plan be financed by a chargeof $2.50 to each participating student, anda charge of $2.50 to each hospital foreach internship filled through the plan.The expenditure of the funds so collectedwill be under the control of the NationalInterassociation Committee on Internships.

The report and the above recommenda­tions were presented to the ExecutiveCouncil of the Association at its meetingin Chicago, by the chairman of the Com­mittee on Internships and Residencies,and was approved. They were similarlypresented to the executive bodies of theother associations which also gave ap­proval. Subsequently, this approval wasratified by the individual components ofthe various associations, as recently re­ported to the schools and hospitals.Following this approval, the temporaryNational Interassociation Committee metin Chicago on Friday, July 27, dissolved,and reorganized itself into a permanentNational Interassociation Committee onInternships. A statement of the organiza­tion, rules of procedure, officers, etc., isattached. The representatives of the Asso­ciation of American Medical Colleges onthe committee are Dr. J. F. Mullin, whois chairman, John Stalnaker and yourchairman. The Association of AmericanMedical Colleges headquarters is desig­nated as the operating agency and Mr.Stalnaker is director of operations.

The success of the cooperative plan for1951-52 of machine matching and estab­lishment of the National Interassociationon Internships has not obscured other prob­lems of the internship, several of whichare basic and very important. A numberof members have indicated to the chair­man and to the committee their concernwith these problems and the need tostudy and solve them. The committee re­grets that it has not, so far, been able toact on the resolution of Panel J of theRound Table held at the meetiqg in LakePlacid ("Specific Internship Requirementsfor Licensure-Yes or No"), which wasreferred to it by the Executive Council.The committee is aware of these problemsand the need to investigate them. In thisconnection it may be noted that the Coun­cil on Medical Education and Hospitals ofthe American Medical Association hasorganized an Advisory Committee onInternships of which your chairman isa member. The' establishment of theNational Interassociation Committeeshould relieve your Committee on Intern­ships and Residencies of the details ofthat activity and free them for a studyof other important internship problems.

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

Accepternce

The annual report of the Committee onInternships and Residencies was acceptedwithout revision at the Business Meeting,Tuesday, October 30.

Planning Committee forNational Emergency

STOCKTON KIMBALL, chairman: ThePlanning Committee for National Em­ergency has held no independent meetings,but has worked in conjunction with theCouncil on Medical Education and Hospi­tals of the American Medical Associationthrough the Joint Committee on MedicalEducation in Time of National Emergencywhich represents both associations.

The actions of the joint committee haveincluded the following:

1. Completion and publication in No­vember 1950 in the journals of bothassociations of the Statement of the JointCommittee on Medical Education in Timeof National Emergency. Copies of thisstatement were sent to the Rusk Commit­tee, National Resources Planning Boardand each of the medical schools.

2. A questionnaire study of the possibil­ities of expanding medical schools' enroll­ment was made with the cooperation ofall of the medical schools. The resultsindicated, that there has been a high de­gree of expansion in enrollment since theend of World War II, and any furtherdegree of expansion in any considerablenumbers would involve the need of secur­ing funds for expanded faculties and formedical school and hospital construction.

3. Compilation in January 1951 by asubcommittee consisting of Arthur Bach­meyer, Harold Diehl, Edward Leveroos,Victor Johnson, chairman, of suggestionsconcerning policies for faculty, residentand graduate student deferment. Thesesuggestions were brought by Dr. Diehl tothe Rusk Committee and were later in­corporated in Information Bulletins ~4

and #5 released by the National AdvisoryCommittee of Selective Service. Thesebulletins made provision for the possibil­ity that occasional members of the basicscience faculties who were in a one ortwo priority might be recommended fora 2A occupational classification on thebasis of essentiality pending search forreplacement. Likewise, occasional resi­dents in rare categories in low prioritiesmight be recommended for one or twoyears of residency training.

4. Members of the joint committee ap­peared at a hearing on January 30, 1951,

62ND ANNUAL MEETING

before the Subcommittee of the SenateArmed Service Committee. A statementmade at that time was circulated to theschools.

5. Compilation by a Subcommittee onCurriculum of a series of suggestions forsupplementing the medical curriculum intime of national emergency. The subcom­mittee consisted of Gaylord W. Anderson,G. M. Dack, Roy R. Grinker, RogerA. Harvey, Andrew C. Ivy, H. WorleyKendell, Franklin P. McLean, John P.Marbarger, Charles B. Puestow, StanleyW. Olson, chairman. Consultants from thegovernment services cooperated in thepreparation of this report. The report wasadopted at the meeting of the joint com­mittee in February 1951, printed in theJournal of the American Medical Associa­tion, and 25 copies were sent to eachmedical school for their guidance in in­corporating the material into their exist­ing courses or for providing any new in­struction that seems indicated.

6. Consideration was given to the re­port presented on February 12, 1951, beforethe Congress on Medical Education andLicensure, by Dr. Howard Rusk, entitled,"Medicine, Mobilization and Manpower."This was followed' by a hearing held bythe joint committee on March 8, 1951,with the Rusk Committee concerning thisreport. At this meeting the conclusionsand the basis for the conclusions wercargued.

7. Members of the joint committee par­ticipated in a hearing on August 17, 1951,concerning universal military training andits impact on medical education. Thishearing was held before the NationalSecurity Training Commission which ispreparing a report due to be released bythe end of October 1951.

8. A meeting of the joint committee washeld at French Lick October 27, 1951.

Accepternce

The annual report of the Planning Com­mittee for National Emergency was ac­cepted without revision at the BusinessMeeting, Tuesday, October 30.

Committee on PostdoctoralEducation

JOHN TRUSLOW, chairman: The commit­tee on Postdoctoral Education was ap­pointed by letter from the Associationoffice in February 1951. However, exceptfor two interchanges of letters duringthe past seven months no full committeemeeting has occurred until this week.

73

ao<.l:11::(1)

a8o

Q

Therefore no report was prepared in ad­vance of the Association meeting.

The most productive session took placein the presence of a number of membersof the Association who assembled for thepurpose of discussion of a report. Thisreport, on general principles and generalscope of the committee's interests, there­fore results largely from this assembly.

Four general principles appeared to findthe group in essential agreement:

1. The primary concern of the commit­tee at present shall be the continuouseducation of the physician, including thoseareas closely related to that type of train­ing generally understood in the term"graduate education."

2. A fundamental component of a suc­cessful program of continuous educationis close associatiop in the planning andinformation phases between the medicalschools and the medical community in­volved.

3. Methods of evaluating programs areurgently needed, dealing not only withprofessional excellence but also witheffectiveness in terms of numbers of in­dividuals involved and response to theirneeds.

4. Regional studies and interchanges ofinformation in areas with similar problemswere proposed, emphasizing the value ofsharing experience in the use of specialtechniques, periodicity of programs, con­tent problems and other matters relatedto the special character and circumstancesin the local physician population.

5. A meeting of the committee isplanned in Chicago at the time of theCouncil meetings in February, and lead­ing up to this meeting there will be activeconsideration of additional membershipsuggestions with particular reference toregional distribution.

Acceptance

The annual report of the Committee onPostdoctoral Education was acceptedwithout revision at the Business Meeting,Tuesday, October 30.

Committee on Public InformationLOREN CHANDLER, acting chairman:

American medical schools have a greatstory to tell. Medical education, researchand health service have great news value.We have done a poor job of telling ourstory.

Our medical schools should give infor­mation and publicize themselves in thefollowing ways:

74

1. Intra-university publicity. There arethree main channels through which thistype of publicity may be achieved. First,university publications such as house or­gans or alumni journals may be utilized.Second, medical school faculty conferencesand meetings, to which members of thefaculty from social and clinical sciences,law and other college departments are in­vited, may be used. Third, some procedureor technique may be established wherebythe university board of trustees is keptwell informed jibout the medical school.

2. Public information activities at thelocal community and state level with themedical profession. Information alsoshould go to medical and nonmedical uni­versity alumni, the lay public, industryand others.

3. Establishment of practical workingarrangements with local newspapers,news services and radio and televisionstations. This may be accomplished bymeans of personal acquaintance, learningeach other's ethics and code, telling theentire story, being available for the press24 hours a day, inviting science writersfrequently to meet, talk and lunch withfaculty members.

Other methods of establishing workingarrangements may include the prepara­tion of feature stories on education andresearch; conducting displays and confer­ences on medical education; research andservice; medical school participation inthe medical seminar of the American Col­lege Public Relations Association.

4. Establishment of an Association ofAmerican Medical Colleges public in­formation office with adequate budget,directed by a full-time, experienced pub­lic relations man, preferably one with ex­perience in journalism. Such an officecould do all the above things at the na­tional level on behaU of· all medicalschools. It also could cooperate with theNational Fund for Medical Education,various foundations, federal and state de­partments and other groups. It would beavailable to advise and help individualschools with their public informationefforts.Acceptance

The annual report of the Committee onPublic Information was accepted withoutrevision at the Business Meeting, Tues­day, October 30.

Committee on StudentPersonnel Practices

CARLYLE F. JACOBSEN, chairman: The

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a§oQ

director of studies, John M. Stalnaker,has prepared for the committee, and un­der its direction, the following report:

The work of the Committee on StudentPersonnel Practices is handled throughcommittee meetings and the work of apermanent staff located in the Associationoffice under the director of studies who isresponsible to the committee. The workis financed by special grants and revenuefrom testing. The committee met on Oc­tober 15, 1950, and again on June 2, 1951.The following activities have been underway during the year under report.

1. The Medical College Admission Testwas administered for the committee bythe Educational Testing Service on No­vember 6, 1950, and May 12, 1951, at 276supervised centers located throughout thecountry. Although the committee hashoped that the May test would be thechief administration, 8,555 applicants tookthe test in November as contrasted with6,407 in May. Thus a total of 14,962 stu-

- dents were tested. Over 70,000 individualscore reports were sent to the medicalschools during the year. In addition, eachschool is sent a book listing every studenttested and his scores.

Reports of score distribution of the ap­plicants to each medical school were pre­pared and sent to that school. Distribu­tions of scores for the undergraduate col­leges also were prepared and sent to theindividual colleges for their informationand guidance. The committee has voted,for the future, to prepare these distribu­tions for students from the undergraduatecollege based on the past five test ad­ministrations and to send reports to allundergraduate colleges which had 10 ormore students tested during this period.These reports are confidential and not forpublicity purposes.

The pattern of the test has not changedduring the past year. Work is being doneon developing new types of items andattacking new areas for measurementwhich might be significant in the admis­sion work.

A committee of leading educators, un­der the chairmanship of Dr. Dayton Ed­wards of Cornell, has directed the prepa­ration of the science section of the test.

The M.C.A.T. is designed to consist ofmaterial of intrinsic and well establishedvalidity. Each medical college makes theuse of the test results which it believesto be most appropriate to meet its needs.In addition to studies which are under­talren by the individual medical schoolsof the value of the tests, the committee

62ND ANNUAL MEETING

is undertaking to establish permanentrecords of the individuals admitted tomedical school so that the various typesof validity studies can be undertaken inthe near future.

2. Periodic cumulative lists of acceptedapplicants were again published. Thefirst list, prepared on November 30, 1950,contained 349 names, and the 14th andfinal list, published on August 17, 1951,contained 6,289 names. These lists are ofvalue to some of the schools and continu­ation of them is planned. Early reportingof accepted applicants is requested. Lateadmission policies or clerical difficultiesprevented five of the schools from re­porting a single applicant in time to beincluded in the list published on August17, 1951. Earlier reporting would improvethe value of these lists.

3. A report of the applicants for ad­mission to the class entering in the fallof 1951 is now in progress. This studycannot be undertaken in its final phasesuntil all reports from the individualschools have been submitted. Because twoschools did not submit their reports untilafter October 11, 1951, the published re­port has been delayed.

It now appears that slightly more than20,000 individuals made a total of 71,000applications for the freshman class enter­ing in 1951. The decline in the number ofapplicants from the peak year of 1949-50continues. This year there are some 2,200fewer applicants, and almost 11,000 fewerapplications reported than last year. Forthe first time, a study is being made ofthe number of students applying who ap­plied the previous year. It now appearsthat somewhat over 30 per cent of theapplicants are repeats.

A shift from discouraging applicants toencouraging more individuals to apply tomedical school may be necessary, es­pecially for some of the schools havingrestrictions.

The prompt cooperation of most ofthe medical schools and their willingnessto do the necessary checking has greatlyaided in the development of accurate sta­tistics in this important area. The prob­lem of definition and the development ofadequate and workable uniform rules ofprocedure will make these- statistics. evenmore meaningful in future years.

4. With,the aid from a grant from theMarkle Foundation, the records of stu­dents now in medical colleges and thosewho have been in attendance during thepast five years have been put on punchedcards. The accuracy and completeness of

75

:::9rJ)rJ)a\-;(1)

0........;:l0..s::~'"d

(1)u;:l

'"d0\-;

0..(1)\-;

(1)

.D0......

......0Zu

~(1)

..s::......4-<0rJ)

:::9......u~<3

~u(1)

..s::......a0

<.l:11::(1)

a;:lu0

Q

these files are continuing to be checked.It is believed that many types of studiescan be made from these records in thenear future.

5. The study of drop-outs from medi­cal schools has been delayed, but shouldbe published by the first of the year. Hereagain, the problem of definition and theadoption of uniform procedures of report­ing will make this type of study, whichshould become routine, of greater value.

6. A 1951 edition of the admission re­quirements booklet has been publishedand is available for student use. A chargeof $1 per copy is being made this yearto help defray the cost of publication.This booklet, first published last year,has been helpful to many students andespecially to advisors of students. A 1952edition is planned. Medical schools shouldgive complete and accurate informationfor this booklet. •

7. A revision of the handbook for stu­dents planning to enter medicine hasbeen prepared and is now under consider­ation by the committee.

8. Work continues on the developmentof a test to measure interest in the studyof medicine. This field of testing is oneof the most promising ones. The commit­tee, with the aid of a grant from theMarkle Foundation, continues its explora­tory work. It is following closely worknow being undertaken for the armedservices directed toward a differentiationamong the interests of students going intothe various specialties. Some other ap­proaches to the problem also are beingmade by other outside groups which thecommittee is following closely. The com­mittee hopes, in time, to develop a testwhich will be suitable for use with allapplicants.

9. A study of the personality traits ofmedical students at two of the medicalschools, which has been undertaken byDr. Henry Brosin and supported by thecommittee, has completed the first phaseof its work. This is the type of studywhich is continuing and does not lenditself to early reporting. A preliminaryreport has been made, but no significantresults leading to changes of existing poli­cies were made. This work has been fi­nanced in part by the committee, and toa much larger extent, by a special grantto the committee by the Markle Founda­tion.

10. The project on techniques and val­ues of the interview in the admission pro­cedure is under study at the Universityof Utah. A stUdy of the results of this

76

project will be reported during the com­ing year.

11. A faculty roster of all personsteaching 25 or more hours per year inthe medical schools is well along towardcompletion. This project is being donewith the help of the health resources staffof the Office of Defense Mobilization ofthe federal government. Most of the in­formation supplied by the faculty ques­tionnaires has been coded and put onpunched cards. Several preliminary stu­dies have been completed. At the averagemedical school, physicians provide fourout of five hours of all instruction. Aboutthree-fourths of the physician-facultygroup, however, receive less than half oftheir earned income from the medicalschool. On the average, based on thestudy of 50 of the schools, the facultyhours per student are 534, but over twicethis amount was found for three of theschools and four other schools averagedless than 300 hours per student. Of thephysician-faculty hours, research accountsfor 26 per cent. The average faculty agefor the physicians is 46.

The questionnaire approach to securinginformation of this kind has some limita­tions. The tendency for the part-time,volunteer person to overestimate thenumber of hours may be expected. Thissituation can be investigated on a sam­pling basis. The consistency of the datain general suggests that the results willnot be without value.

If the values of a study of this typeappear to be great enough, efforts will bemade to maintain this faculty roster onan up-to-date basis by either annualor biennial corrections. The completepunched card file, which is being preparedby the government, will be available inthe Association office before the first ofJanuary.

12. A statistical study of the freshmanclass which entered in 1950 is now near­ing completion. It is expected that a pub­lished report, including the names of allof the students and their classificationstogether with a statistical summary, willbe published within the next few months.The test scores, age, state of residenceand many other items will be summar­ized by medical school for this group.This class will then be followed throughthe subsequent years of their medicaleducation.

13. The committee handled the dry runof the matching plan for internship place­ment. The director of studies and the en­tire staff devoted a large amount of time

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

to this work. The plan, if supported bythe hospitals and the students, is a feasi­ble one. The mechanical aspects of theplan, which should belong in the back­ground, have been stressed unduly andthe value of the plan, both for the hospi­tals and especially for the students, hasnot been stressed sufficiently.

The committee has lent, without charge,its director of studies to be the directorof operations for the newly formed Inter­Association Committee on Internships.

14. The committee has received an in­creasing number of requests for signifi­cant types of information which it hasnot been able to answer. The informa­tion, so far as can be determined, does notexist in any central spot at this time. Aquestionnaire covering a number of theseitems will be prepared and submitted tothe schools in the immediate future.

15. The suggestion of Dr. Olson at thelast meeting, that the committee explorethe possibility of setting up a central ex­change whereby students who have beenaccepted by any medical school who wishto attend another school be permitted todo so on a one-for-one exchange with themutual approval of the two schools con­cerned, has not led to any practical pro­posals at this time. The committee recog­nizes the grave dangers of the currentstate restrictions and notes with someconcern the extent to which some stateschools are reaching down into the appli­cant group in order to gain a full class.The problem will be given further studyby the committee.

16. The committee again recommendsthat deposits from accepted students netbe required by the medical schools beforeJanuary 15, or approximately sevenmonths before the class instruction starts.Acceptances could be made earlier, butthe committee believes early deposits areunwise. This recommendation is beingmade to the Executive Council for theirconsideration.

Accepfance

The annual report of the Committee onStudent Personnel Practices was acceptedwithout revision at the Business Meeting,Tuesday, October 30. '

Election of Officers for 1951·52Upon the recommendation of the Nomi­

nating Committee, the following officersand members of the Executive Councilwere duly elected:OfficeT~:

President-Dr. George Packer Berry

62ND ANNUAL MEETING

President-Elect-Dr. Ward DarleyVice-President-Dr. Stanley E. DorstSecretary-Dr. Dean F. SmileyTreasurer-Dr. John B. Youmans

Members of Executive Council 1951-52,and 1952-53:Dr. Vernon W. LippardDr. Edward L. TurnerThe other members of the Executive

Council, elected last year for a two-yearterm, are Dr. Joseph C. Hinsey and Dr.C. N. H. Long.

Dinner MeetingSir James Spence of Durham University,

England, gave an informative address atthe dinner meeting, Tuesday, October 30.He described in detail the means by whichgovernment support for higher educationis obtained without political control overthe universities. This financial assistanceis made possible, he said, through the Uni­versity Grants Committee.

Executive Council Meeting ActionsThe meeting of the new Executive Coun­

cil was held on the evening of Tuesday,October 30. A summary of actions takenat the meeting follows:

1. Dr. Joseph C. Hinsey was electedchairman of the Executive Council for theyear 1951-1952.

2. Upon the recommendation of theCommittee on the Journal of MEDICALEDUCATION, authorization was granted theeditor and managing editor of the Journalto begin the publication of a 10 issueJournal beginning January 1953.

3. A budget of $59,380.71 was approvedfor the Medical Audio-Visual Institute(formerly the Medical Film Institute) forthe year 1951-1952.

4. The name of the Committee on Post­doctoral Education was changed to theCommittee on Continuation Education.

5. An ad hoc committee consisting ofDrs. Berry, Dorst, Long, Smiley and Stal­naker was appointed to develop plans fora series of teaching institutes.

6. A committee consisting of Drs. Dar­ley, Lippard and Turner was appointed tostudy and bring in a report on the long­range functions of the Association.

7. Dr. Joseph C. Hinsey was authorizedto represent the Association at the inaug­uration of Harlan Henthorne Hatcher aseighth president of the University ofMichigan, November 27, 1951.

8. Committees and representatives to

77

ao<.l:11::(1)

a8o

Q

other boards and councils for 1951-1952were named as follows:(Chairman listed first-Affiliation listed in

italics)

AUDIOVISUAL EDUCATIONWalter A. Bloedorn, George WashingtonJ. S. Butterworth, New York University

Post-GraduateClarence de la Chapelle, New York Univ.

Post-GraduateJoseph Markee, DukeAura Severinghaus, Columbia

BORDEN AWARDEdward West, OregonWillard M. Allen, Washington U.

(St. Louis)C. N. H. Long, YaleH. P. Smith, ColumbiaAshley Weech, Cincinnati

CONTINUATION EDUCATIONJohn Truslow, Virginia Medical College

(Richmond)George N. Aagaard, SouthwesternRobert Boggs, New York University Post­

GraduateKendall Corbin, Mayo Foundation

(Rochester)Aims C. McGuinness, Pennsylvania

ENVIRONMENTAL MEDICINEDuncan W. Clark, State Univ. of New York

(N.Y.C.)Jean A. Curran, State University of New

York (N.Y.C.)Harry F. Dowling, IllinoisWilliam W. Frye, Louisiana StateDavid Rutstein, HarvardLeo Simmons, CornellErnest Stebbins, Johns Hopkins

FINANCIAL AID TO MEDICAL EDUCATIONVernon Lippard, U. of Virginia

(Charlottesville)George Packer Berry, HarvardWalter A. Bloedorn, George WashingtonWard Darley, ColoradoJoseph C. Hinsey, CornellMaxwell Lapham, Tulane

FOREIGN STUDENTSFrancis Scott Smyth, California (San

Francisco)Maxwell E. Lapham, TulaneC. N. H. Long, YaleHarry A. Pierson, Institute of International

EducationAura E. Severinghaus, ColumbiaEdward L, Turner, U. of Washington

(Seattle)Elizabeth Lam, International Exchange of

Persons

78

E. Grey Dimond, KansasFrode Jensen, New York University Post­

Graduate

INTERNSHIPS AND RESIDENCIESJohn B. Youmans, VanderbiltD. W. E. Baird (Ida., Mont., Ore., Wash.),

OregonParker R. Beamer (Ky., N.C., S.C., Tenn.),

Bowman GrayW. A. Bloedorn (Del., D.C., Md., Va.,

W. Va.), George WashingtonWarren T. Brown (Okla., Texas), BaylorL. R. Chandler (Ariz., Calif., Nev.),

StanfordJ. A. Curran (Conn., N.Y., Part of N.J.),

State U. of N.Y.Charles A. Doan (E. Ohio, W. Penna.),

Ohio StateStanley Dorst (Mich., W. Ohio), CincinnatiReginald Fitz (Me., Mass., N.H., R.I., Vt.) ,

HarvardMaxwell E. Lapham (Ark., La., Miss.),

TulaneH. C. Lueth (Kans., Mo., Nebr., N.D.,

S.D.), NebraskaJohn McK. Mitchell (Part of N.J., E.Pa.),

PennsylvaniaOtto Mortensen (Minn., Wis.), WisconsinFrancis J. Mullin (111., Ind., Iowa),

Chicago MedicalC. J. Smyth (Colo., N. Mex., Utah, Wyo.),

ColoradoR. Hugh Wood (Ala., Fla., Ga.), Emory

Journal of MEDICAL EDUCATIONLowell T. Coggeshall, University of

ChicagoJames Faulkner, BostonRobert A. Moore, Washington University

(St. Louis)

LICENSURE PROBLEMSCharles A. Doan, Ohio StateWilliam R. Willard, State U. of N. Y.

(Syracuse)John P. Hubbard, PennsylvaniaJ. Murray Kinsman, Louisville

LONG RANGE PLANNINGWard Darley, ColoradoVernon Lippard, U. of VirginiaEdward Turner, U. of Washington

MEDICAL CARE PLANSD. F. Smiley, Association of American

Medical CollegesLowell T. Coggeshall, University of

ChicagoJohn F. Sheehan, Loyola

MEDICAL ROT CStanley Olson, IllinoisLawrence Hanlon, Cornell

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

Stockton Kimball, BuffaloJohn Lagen, California (San Francisco)John B. Youmans, Vanderbilt

NATIONAL EMERGENCY PLANNINGStockton Kimball, BuffaloGeorge Packer Berry, HarvardJohn Z. Bowers, UtahStanley Olson, IllinoisJohn M. Stalnaker, Association of

American Medical Colleges

PLANNING FOR TEACHING INSTITUTESGeorge Packer Berry, HarvardStanley Dorst, CincinnatiC. N. H. Long, YaleD. F. Smiley, Association of American

Medical CollegesJohn M. Stalnaker, Assoc. of American

Medical Colleges

PROGRAM COMMITTEEDean F. Smiley, Assn. of American Medi-

cal CollegesGeorge Packer Berry, HarvardRobert Lewis, ColoradoHarold Lueth, Nebraska

PUBLIC INFORMATIONL. R. Chandler, StanfordGeorge N. Aagaard, SouthwesternJohn L. Caughey, Western ReserveRalph Rohweder, National Society for

Medical ResearchDean F. Smiley, Association of American

Medical CollegesJohn D. Van Nuys, Indiana

STUDENT PERSONNEL PRACTICESCarlyle Jacobsen, State University of New

YorkGeorge Packer Berry, HarvardD. Bailey Calvin, TexasJohn Deitrick, Survey of Medical

EducationThomas Hunter, Washington University

(st. Louis) ~

Richard H. Young, Northwestern

VETERANS ADMINISTRATION·MEDICAL SCHOOL RELATIONSHIPS

R. Hugh Wood, EmoryHarold Diehl, Minnesota (Minneapolis)Reginald Fitz, HarvardR. Arnold Griswold, Louisville

Representatives to Related Organizations

ADVISORY BOARD FORMEDICAL SPECIALTIESL. R. ChandlerStanley Dorst

62ND ANNUAL MEETING

ADVISORY BOARD OF AMERICANFOUNDATION OF OCCUPATIONAL HEALTHDean F. Smiley

ADVISORY COUNCIL FOR THE NATIONALFUND FOR MEDICAL EDUCATIONArthur C. BachmeyerWalter A. BloedornJoseph C. Hinsey

ADVISORY COUNCIL ONMEDICAL EDUCATIONWard DarleyJoseph C. HinseyVernon W. Lippard

AMERICAN COUNCIL ON EDUCATIONRev. Paul A. McNallyWilliam T. SangerWilliam R. Willard

ARMED FORCES MEDICALADVISORY COMMITTEEStockton Kimball

COMMITTEE FOR THE COORDINATIONOF MEDICAL ACTIVITIESDean F. Smiley

COMMITTEE ON SURVEYOF MEDICAL EDUCATIONArthur C. BachmeyerJoseph C. HinseyDean F. Smiley

COUNCIL ON NATIONALEMERGENCY MEDICAL SERVICEStockton Kimball

EVALUATION OF FOREIGN CREDENTIALSFrances Scott SmythDean F. Smiley

FEDERATION OF STATE MEDICAL BOARDSDean F. Smiley

FELLOWSHIPS SELECTION BOARDWalter A. Bloedorn

INTERASSOCIATION COMMITTEEON INTERNSHIPSF. J. MullinJohn M. StalnakerJohn B. Youmans

JOINT COMMITTEE ON MEDICAL EDUCATIONIN TIME OF NATIONAL EMERGENCYStockton KimballGeorge Packer BerryJoseph C. HinseyDean F. SmileyJohn M. Stalnaker

LIAISON COMMITTEE WITH COUNCIL ONMEDICAL EDUCATION AND HOSPITALSGeorge Packer Berry

79

Summary of Round Table Discussions

NATIONAL ADVISORY COMMITTEEON LOCAL HEALTH UNITSCurrier McEwen

NATIONAL BOARD OF MEDICAL EXAMINERSL. R. ChandlerRobert A. MooreB. O. Raulston

NATIONAL HEALTH COUNCIL.Joseph C. HinseyIra HiscockCurrier McEwen

MINUTES OF THE PROCEEDINGS

comments from the floor developed certainaspects which may be summarized as fol­lows:

First, house staff training in regionaJhospitals. In some areas experience hasbeen gained in the rotation of residentsselected by affiliated community hospitalsthrough a university hospital. A plan wasdescribed in which the resident, after ayear in the affiliated hospital, spends anequal time in the University of Michiganhospital to obtain training mainly in thebasic sciences. SUbsequently he returns tothe affiliated hospital to complete his resi­dency and extend his clinical experience.The Kellogg Foundation initially coveredthe cost of this program. It now is beingborne by the University of Michigan andthe physicians practicing in the affiliatedhospitals.

An example of hospital affiliation forintern training was described as developedby the Medical College of Virginia,through the aid of the CommonwealthFund, and now with the participation ofthe University of Virginia. This plan pro­vides for a six-week to three-month ex­perience on the part of the intern in ahospital affiliated with the university hos­pital.

The general. discussion developed thelarge part that such house staff programsplay in the postgraduate education of thephysicians in the community in which theaffiliated hospital is located. Since suchprograms are possible only if members of

MEDICAL ADVISORY COMMITTEE OFINSTITUTE OF INTERNATIONAL EDUCATIONDuncan W. ClarkDayton EdwardsAura SeveringhausFrancis Scott SmythTravers C. Stepita

Stanley Dorst.Joseph C. HinseyDean F. Smiley, ex-officio

Panel discussions on the topics that fol­low were held on the first day of the An­nual Meeting. Round Table members arelisted on page 7. The following reportsare summary statements by the chairmenor recorders for each group, and were pre­sented Wednesday morning, Oct. 31:

Round Table 1Regional Hospital Plans and ContinuationEducation of PhysiciansR. H. Kampmeler. chairman.

The chairman opened the discussion bystating that medical schools should andmust be interested in the level of medicalpractice in their communities. Further­more, the schools should give the assist­ance necessary to maintain professionaladequacy in the care of the patient. Itwas indicated that the regional hospitaloffers an important facility for continua­tion education of the practitioner. Thepresentations by the members of thepanel were designed to cover:

(1) The need for continued study onthe part of physicians in private practiceand methods by which this can be accom­plished.

(2) The content of continuation educa­tion for physicians.

(3) Continuation study in regional hos­pitals on a house-staff level.

(4) The use of the regional hospital asa teaching center by visiting teachersfrom medical centers.

These discussions and questions and

80

ao<.l:1

ao<.l:11::(1)

a8o

Q

the university hospital staffs make peri­odic teaching visits to the affiliated hos­pital and only if certain members of thestaff of the hospital assume the obligationof teaching the house staff, donating muchof their time and energy, such activitiesmust result in a higher level of practicein the hospital. If the private patients ofthe hospital are used as teaching cases,again the level of practice cannot help butbe improved. The betterment in medicalrecords, laboratory and other ancillary fa­cilities must certainly be reflected in bettercare of the sick of the community. Thepart the visiting pathologist plays is ofinestimable value in the reduction of un­necessary operations.

Discussion also brought out the constantneed for supervision of the policies of theaffiliated hospitals to assure no lag inteaching interest on the part of the staff,nor the degeneration of a teaching pro­gram into the utilization of the house staffas mere service personnel. It was feltthat the costs of such programs must belaid in large part on the shoulders of theaffiliated hospitals. These house-staff pro­grams have resulted in some instances inthe location of young doctors in nonurbancommunities.

Second, continuation education of phy­sicians in practice. This subject permitteddescriptions of a number of systems inuse. In some instances educational pro­grams have been begun by medical soci­eties; in others the medical schools havetaken the initiative in establishing post­graduate instruction for doctors. In eithercase, the collaboration of state medicalsocieties and other bodies is highly de­sirable.

One of the methods of instruction util­ized by the New England Medical Centerconsists of supplying the family physicianwith a complete transcript of the patient'shospital record on the occasion of hos­pitalization. This represents a case dem­onstration on the physician's own patient.It is accompanied by abstracts of teachingmaterial culIed from the current litera­ture.

A common method of providing contin­uation training is the so-called "circuit­riding" type, by which members of theuniversity hospital staff visit smaller com­munities to instruct physicians of a givenarea. The several methods described bythe members of the panel varied only indetail. It was generalIy agreed that suchteaching should be clinical and not didac­tic, that patients of the local doctorsshould provide the material for case dis-

62ND ANNUAL MEETING

cussions and that the teaching be carriedout in the local hospital. The need forestablishing regularity in such visits wasemphasized so that such teaching servicesbecome a part of the doctor's routine. Insome states this type of teaching hasreached a high proportion of the physi­cians in the rural areas.

The "circuit-riding" type of continua­tion education amplifies and complementsthe refresher type of teaching given in oneto five-day sessions at the university hos­pital. This type of instruction has had abackground of years of experience in someof the schools represented by members ofthe panel. Again the content and detailsvary, but such courses permit possiblymore organized and specialty presenta­tions than does the "circuit-riding" type.

An interesting training development inthe Kansas postgraduate plan is the des­ignation, by one means or another, of onepractitioner in a community to become theinterpreter of laboratory findings, anotherof x-ray films, another for anesthesia.These men receive varying periods oftraining at the university hospital.

The general discussion included thevarious methods of financing the activitiesof continuation education. In the field ofhouse-staff training by hospital affiliation,it was felt the hospital should assume themajor burden of the expense. However,in the case of state supported medicalschools, they may make a contribution interms of staff activities without additionalremuneration. Foundations have playedtheir part in the development of theseplans.

In the field of postgraduate education itwas brought out that tuition paid by regis­trants may well carry the expense of re­fresher courses. Similarly, a tuition feemay contribute to the "circuit-riding" typeof education as also do special agencieswith moneys colIected for the control ofcertain diseases. More effort should bemade to obtain contributions from statemedical societies and the Academy ofGeneral Practice, as is already done insome areas.

Finally, there was extended discussionas to just what continuation education ofthe practitioner has accomplished. Has itled to better medical care of the sick inthe nonurban areas? It was generallyagreed that this question cannot be an­swered by any statistical or scientificmeans. The only evaluation at the presenttime is that of impressions on the part of­those engaged in postgraduate teaching;admittedly these may be biased by en­thusiasm. Nevertheless, it seems that im-

81

ao<.l:11::(1)

a8o

Q

provement Jtl medical rccords and betterutilIzatIOn of diagnostic aIds In the smallhospital may offer some concrete evidenceof a measure of success The more pomtedquestIons and better case analysis, as eval­uated With the passage of time by the"clrcuit-nding" teacher as he makes hisrounds, offer evidence of better thinking111 relatIon to medIcal problems than ayear or more before. Of necessIty profes­SIOnal ethlc~ must improve as doctors in al'ommumty are thrown together in a com­mon project for their mutual improve­ment. and as each is humbled In theOthN'S pr('sence 111 case discussions whichpomt up errors m dIagnosis and judgment.

Members of the panel and discussantsfwm the floor at no tIme raIsed any ques­tIOn as to whether contmuation educationI::. to be discarded The need for such edu­catIon IS Without questIOn The problems\\ hlch remain are: first, \\"hlch methods ofteachmg will give the best results, andsecond, how may th('~e results be meas­ured

Recommendations:(1) The panel members r('commend that

~tudy should be gIVen to developing meth­ods whereby an evaluation may be madeof the impact of contll1uation educationupon the quality of medical care 111 acommunity;

(2) Furthermore, that methods be ex­plored for encouragmg practitioner~ top<1rtlclpate in contmU<1tion education

Round Table 2The Threat of Large Scale Research Pro­grams to the Cj)uality of Medical EducationRichard H. Young. chairman.

As a result of \VIde general dISCUSSIOnthe f,,!lowing conclUSIOns were reached:

1 That large scale research programsrepresent no threat to the quality of medi­cal educatIOn prOVIded they are adminis­tered WIsely, both by the granting agenciesand the recipient 1I1stItutions.

2. That the best guarantee for soundC'dminbtration on the part of the grantingagencIes I~ the system of broad represen­tatIOn from univerSItIes and colleges onthe counCIls that develop their policies andon the panels of experts that scrutinizeapplIcatIons.

3. That many of the problems which arcraIsed by large scale research programswould be met If the teaching programs inmedIcal schools were adequately financed.

4. That a resolution be presented to theEXf>cutive CounCil recommending that the

32

ASSOCIatIon of AmerIcan MedIcal Collegesundertake a study to determine the actualcost, direct and indirect, of research, witha view of reaching a more adequate anduniform basis for discussion of overheadcharges with fund-granting agencies.

Round Table 3Medical Teaching on the Ambulant PatientDavid Barr. chairman.

Dr. Barr described the intrinsic featureswhich have brought medical education toIts outstanding position in our modern so­ciety. In a large measure this was at­tnbuted to careful and meticulous atten­tion to anatomical and chemical defects\\"Ith remarkable and inspiring advancesin the solution of such problems. How­ever, there is a distmct danger that sucha procedure can, and in fact often does,become a stenle intellectual exercise withlittle regard for the understanding or ap­preciation of the patIent and his problem.

It is essential that the student be taughtto evaluate the SOCIal, economic, emotionaland envIronmental factors in the patient'sday-to-day life which often are of theutmost importance in respect to the properunderstandmg of the Illness situation. Hemust consider the patIent and his family aswell as the disease, and evaluate the sig­nificance of one in relation to the other. Itis essential, therefore, that the student be­come familiar with the background of dis­ease from a comprehensive point of view.

Ward teaching 111 many instances hasreached a peak of unparalleled excellence.yet it inherently retains certain specificlimitations. It represents an exercisewhIch deals with but a small componentof the total number of sick people, It isan experience which deals with a briefand isolated circumstance in the patient'slife rather than the result of a prolongedperfod of observation. Perhaps most sig­mficantly it represents a conclusion basedon a series of observations on a subjectwho has been displaced from his normalmilIeu, and thus may be deceiving andartificial.

The obvious solution lies in the Increas­ing utIlIzatIon of the ambulant patient orthe outpatIent department. Simple as thisanswer seems to be, it produces certainproblems which deserve careful consid­eration. Steps must be taken to insure anadequate degree of continuity in patientcare and the leanung experience. Hurried,strained and brief observations made onthe sick person are all too obvious preclu­sions to good teaching. Measures should

MINUTES OF TIlE PROCEEDINGS

aor.l:11::(1)

a8oQ

be taken to prevent and control the prob­lem of overcrowdmg in the clinic. It isdesirable that a fUll-time and dedicatednucleus of teachers form the center aroundwhich the instructional staff may be de­veloped. This should include experiencedteachers who by precept and example im­press on the mind of the student the na­ture of disease and the sigmficance of thedoctor-patient relationship. Of no smallassistance would be the interdepartmentalcorrelation of clinical activities whichbring to bear on any given problem thespecial skills, experience and knowledgewhich will be of benefit to both patientand student. In this vein there must alsobe included additional faCilities for medi­cal care such as the visiting nurse andsocial service departments.

Ultimately, in order to appreciate fullythe significance of social, economic, emo­tional and environmental factors as theyrelate to illness situations, medical educa­tion must include facilities which Willmake it possible for the student to studythe patient in his normal environment,namely, the home. In this respect it alsomay be wise to consider the inclusion ofthe humanities in the mainstream of medi­cal education.

Dr. Lester J. Evans: The interest in themedical care of the ambulant patient andthe use of the ambulant patient for medi­cal teaching purposes are symptomatic ofthis present period of transition m medi­cine. The ambulant patient is becoming asymbol of forward-looking medical devel­opment.

The historical perspective of medicineas viewed over the last 40 or 50 yearsgives indication why the ambulant patientIS becoming increasingly a principal focalpoint of medicine.

"As we view the historical perspectiveof medicine, it seems to me that develop­ment has been along three pnncipal routesor avenues which have now reached apoint of confluence or merger. Theseroutes are scientific clinical medicine, pub­lIc health, psychiatry and social studie!>.

"Scientific clinical medicine has resultedfrom phenomenal advances in the medicalsciences whereby the nature of many dis­ease processes has been revealed. The dis­ease was the point of departure. Knowl­edge of the normal accrued largely as aby-product. The host was studIed only asit became necessary to understand a dis­ease process. In our modern educationalsystem the university medical center hasbecome the symbol of scientific medicine.It is there that the findings of the basic

62ND ANNUAL MEETING

sCience laboratory are translated mtostudy of human physwlogy and pathology.The teaching and research hospital is theprincipal focal point around which thegrowth of medical education has takenplace in the last 40 years.

"Paralleling the de\'elopment of scien­tific medicme there grew up in the com­munity, and m fact outside UnlVersity andmedical education circles, many actiVItieswhich are collectively refelTed to as pul>­lic health. The concept of preventlOn 111

modern medicine stems from the successin first preventmg the spread of com­municable or mfectIous diseases by at­tackmg certam environmental situations,dnd next by altering the character of thehost through immunological procedures soIt was no longer susceptible to specificmfectious agents. So popular has the con­cept of prevention become that it has beencarried to almost hazardous extremes byholdmg out f31se promises in fields wherelIttle is known of the nature of health orillness proces~es. The scientific underpin­nmgs of publIc health derive from thebaSiC SClCnces of medicine. The principaloriginal contnbutlOn from publIc health tu!>clCntific procedure has been the brilliantapplication of the quantitative method tothe study of community and other mas~

phenomena. ThiS IS one way in whichmedicine has had opened up to it the op­portunity to study the human bemg inrelatlOn to the events takmg place m hiSnatural environment.

"Offhand it might seem that we nowhave all that is needed to interpret thehealth and illness of human bemgs d!> anadaptive process-the dynamic relat1OlI­ship between the organism and Ib en­vironment. But that cannot be done With­out turning to a third stream of medicalprogress which is emerging through p!>y­chiatry and psychology. Modern psychI­atry has helped us understand that thehuman being really functions as an lll­

tegrated whole. The evidence has comemost strikingly from the joint efforts otpsychiatry and scientific medicine in thestudy of the relationship of such phe­nomena as hypertension, asthma, gastnculcer and headache to the lIfe situationsof patients. The expressIOn 'life SitUd­

tion' immediately calls for conceptuali­zation in terms of movement through tlmLand in relation to the total environment.the human elements of It as well as the 111­

fectious, physical or nutntious Thus thedynamic nature of life plocesses IS fUl thel'emphasized and the human element otenvironm('nt st3nd~ Ollt in \;. Ilrl rell('f

ao<.l:11::(1)

a8o

Q

"It seeems to me that the developmentof medicine in recent decades, as I havetried to describe it, brings us to a pointwhere we can approach the study ofmedicine on a somewhat broader basisthan has been customary. Instead of think­ing primarily of specific fields, depart­ments and skills, possibly we are now ina position to think more clearly about thebasic biological concepts which are in­volved and which can be used in the plan­ning of our future educational efforts. Irefer to such concepts as the integrity ofthe living organism (wholeness), growthand development (movement), organism­environment relationships (relationships),and other basic phenomena of which youare well aware. These give meaning tothe expression 'dynamic' as now used inmedicine and biology in understandingthe forces at play and the manner inwhich they affect the development andbehavior of the living organism." 1

Of these basic concepts it is that of theorganism-environment relationship whichinterests us most in this discussion. (a) Theambulant patient is never entirely re­moved from his environment. (b) Theambulant patient is not studied at one sit­ting but rather through a series of contactsthrough time. (c) As the interest of medi­cine moves toward a consideration of theenvironment, we can follow the ambulantpatient into that environment quite easily.(d) This environment is, as we havepointed out, all inclusive.

The human environment is actually so­ciety. Thus, by dealing with the ambulantpatient in all aspects of his living, we aredealing with him in society. But to under­stand society, medicine needs much helpfrom the sociologist, social psychologist,cultural anthropologist, economist, politi­cal scientist and so forth.

As medical education gives increasingemphasis to the environmental componentof the organism - environment complex,medical teaching institutions in one wayor another will in the years to come de­velop outdoor laboratories. These outdoorlaboratories may quite well attain the sig­nificance in the years to come that theindoor laboratories of medical education­the hospital ward, the basic science lab­oratory and so forth-have in past dec­ades.

1 "The Metamorphosis of Preventive Medicine"by Lester J. Evans, M.D., Commonwealth Fund,New York, ConfeTf!11ce of Professors of Preven­tive Medicine Newsletter, Vol. 2, No.1. March,1951.

84

We end up, therefore, with the proposi­tion that whereas medicine has developedup to this time primarily around the prob­lem of the bed patient, medicine of thefuture is quite likely to grow and evolvearound the problem of the ambulantpatient. It is around the ambulant pa­tient that some of the newer fields ofmedicine and the newer concepts of medi­cal care such as preventive medicine, psy­chosomatic medicine, newer and broaderuses of public health, the hospital andother facilities will evolve.

Dr. Stanley Dorst: Dr. Dorst looked backsome 25 years to consider what were atthat time the fundamental thoughts in re­spect to adequate teaching in the dispen­sary. This included five major objectives.The first was to create dispensary facilitieswhich would reproduce as nearly as pos­sible the pattern of private practice. Thesecond was to develop an appointmentsystem which would provide a satisfactorydegree of continuity for both student andpatient. The third element was the crea­tion of facilities which would control anddisperse the patient load in such a fashionthat education could go on unimpaired andpatient care continue at a satisfactorylevel without overwhelming the staff. Thefourth requirement was to provide a suffi­cient block of time in the curriculum forthe student to become properly and ade­quately oriented in the problem of medicalcare in dealing with the ambulant patient.The fifth and perhaps the most significantpoint was a conviction that senior mem­bers of the staff had a personal responsi­bility for teaching and patient care in theoutpatient department.

These were the thoughts which even­tually materialized at Cincinnati. Thephysical establishment to accomplish theseaims became a reality. Students were pro­vided with a four-month experience in theclinic with the same instructors and func­tioned in a central office and examiningarea. It was felt that good teaching re­sulted from following this preconceivedpattern. It was further indicated that ifan outpatient department was unsatisfac­tory as an educational experience, it wasbecause the teachers were second-rate.Therefore, every member of the medicalstaff was required to assume responsibilityfor the outpatient department as well asthe inpatient service.

There also were difficulties which werenot apparent at the onset. The appoint­ment system resulted in a piling up ofpatients and the consequent need for ascreening procedure. This was accom-

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

plished by the development of a preclinicwhich provided for patient selection anddistribution. It also became apparent thatsome measures were necessary for the dis­position of emergency situations and pa­tients with acute short-term illnesses. Theanswer to this problem proved to be areceiving clinic in which patients couldactually be retained for treatment for aslong as 24 hours. A third problem was thespecialty clinics which gradually contin­ued to expand and siphon off patients. Thecorrection of this problem was obtainedby the simple expedient of converting thespecialty clinic to referral clinics so thatthey could return to their intended func­tion of providing a consulting service.

Dr. Henry J. Bakst: The home medicalservice of the Boston University School ofMedicine operates within the admiriistra­tive framework of the outpatient depart­ment of the Massachusetts Memorial Hos­pitals. This activity provides medical carein the homes of those needy and medicallyneedy individuals living in the south endof Boston and an adjacent portion of Rox­bury who request its services. This slumarea contains a 1l0pulation of about 50,000.Some 15,000 home visits are made to 5,000patients annually. About 35 per cent ofthe patients cared for are recipients ofsome form of official financial assistance,such as general relief, aid to dependentchildren and old age assistance. The re­sponsibility for the provision of medicalcare in this area has been a function ofthe Massachusetts Memorial Hospitals formore than 75 years. During this time ithas served as an educational activity ofthe medical school. The utilization of thisservice as an educational facility is theresponsibility of the department of pre­ventive medicine.

Fourth-year students, carefully super­vised, are given a great deal of responsi­bility for patient care. Actually about 75per cent of the patients on this service arecared for at home. About 7 per cent of thepatients are hospitalized at either theMassachusetts Memorial Hospitals or theBoston City Hospital. The remainder arereferred to the outpatient department forfurther investigation.

The organization of the administrationof medical care for patients on this serviceparallels that of care within many teach­ing hospitals. Patients are seen by fourth­year students, checked by residents andsupervised by the hospital staff. There is,however, one striking difference in thatthe student sees the patient first, in thepatient's home and, throughout his ex-

62ND ANNUAL MEETING

perience, the student is the' individualthrough whom medical care is made avail­able to the patient. A very specific andsuccessful effort is made to maintain thestudent in the position of family doctor orgeneral physician for the area to which heis assigned. :r'he supervising residents, in­structors and those who provide specialservices act in the capacity of coqsultantsand advisors. The reaction of the studentto this experience has been most gratify­ing and stimulating.

The educational benefits of this programpresent a number of interesting aspects.Such a service requires that those re­sponsible for instruction teach clinicalmedicine on a very practical level. Theproblems of adequate patient managementin the home must be anticipated to avoidstraining or embarrassing the student'srelationship with his patients. The pre­ventive aspects of disease as related to theindividual and his family and the signifi­cance of social, environmental and emo­tional factors on illness situations are fre­quent problems of major concern. Asource of constant gratification is the sur­prising rapidity with which students whoare obviously diffident and anxious at theonset of the assignment become confidentand assured. Students, almost without ex­ception, develop a broad sense of socialresponsibility which has been one of themost satisfying dividends of the entireprogram.

The learning process in medicine beyondpreclinical training and familiarity withthe natural history of disease is largely amatter of active participation in a clinicalmedium. In this regard, two considerationsof the utmost significance are those re­lated to the extent of personal responsi­bility which the student is allowed in hisclinical activities, and the degree of con­tinuity which is possible in his relation­ship with patients. While a significantdegree of responsibility is given to stu­dents on the home medical service, a one­month continuity assignment is obviouslytoo brief a period to provide a significantdegree of continuity in patient care. Inorder to meet this need, among other rea­sons, a family study program was insti­tuted within the framework of the homemedical service.

This venture was' instituted three yearsago. It consisted of selecting from theregular clientele of the home medicalservice a family for each member of thethird-year class. These families were as­signed at the onset of the third year. Thecriteria for family selection were that the

I 85

ao<.l:11::(1)

a8o

Q

family unit include several young chil­dren and one member with a chronic ill­ness. A detailed outline of the objectivesof the assignment was given to each mem­ber of the class. A preliminary report onthe family was required in three monthsand the student continued as. the medicaladvisor to his family throughout the thirdand fourth years. Since the fourth yearoperates on a 12-month schedule, eachstudent followed his family for a period ofabout 20 months.

The objectives of this program included:1. Supervised responsibility of the stu­

dent in the medical management of suchacute problems as arose during the periodof the assignment.

2. Observation and responsibility forthe medical management of a chronic ill­ness in the home.

3. Immunization of children and the de­velopment of concepts of disease preven­tion within the family unit.

4. Evaluation of' social, environmental,emotional and economic factors in rela­tion to illness situations in the family.

5. Development of familiarity with pub­lic and private resources for medical carein the community.

A final report was required of each stu­dent in the latter half of his fourth year.An interesting outcome of this programwas a series of panel discussions in whichfamilies illustrating problems in tubercu­losis, diabetes, epilepsy, rheumatic heartdisease or asthma were held with the en­tire third-year class. The student pre­sented a summary of his "family" and thepertinent illness situation. This was fol­lowed by a brief discussion by eachmember of the panel, which included arepresentative from the departments ofmedicine, psychiatry and preventivemedicine as well as social service. Theobjective was to discuss the specific prob­lem from the clinical, emotional, preven­tive and social points of view. Thepresentation by panel members was fol­lowed by a general discussion in whichthe entire class participated. These exer­cises proved to be one of the most popu­lar in the third year.

Three additional features were essentialelements in the family study program. Apsychiatrist, who is a member of the de­partment of preventive medicine, conduct­ed a series of individual conferences witheach member of the class. The initial meet­ings were concerned with interviewingtechniques and the approach to a patient.Subsequent conferences dealt with theevaluation and interpretation of the accu-

86

mulated material and, finally, a discussionof patient management.

A second series of conferences was con­ducted by an older, experienced and ableinternist, who met the class in smallgroups for a series of general discussions.These were based on questions raised bystudents in respect to the proper manage­ment of various problems encountered inthe home. Two younger practicing physi­cians were available daily, on a part-timebasis, to accompany the student to thehome in order to check physical findingsand to control the management of currentproblems as well as outline the programfor long-term care.

Inclusive and satisfactory as this pro­gram appeared to be, a series of pitfallsquickly became apparent. Students readilydetected an artificial aspect of the programin that the families to whom they wereassigned, although in need of medical care,did not actually request medical attention.A review of the reports made it amplyclear that students were unprepared toapproach and observe a family group inthe outlined manner. Except in unusualinstances, the student was apt to dispersehis efforts among various members of thefamily together with an obvious tendencyto stress social issues to the detriment ofthe clinical -problems with which he wasconfronted. Not the least difficulty was theusual dispersion of fourth-year students invarious hospitals and assignments so thatfor varying periods they were either notavailable or did not have sufficient timeto visit their families. Despite these handi­caps, the rapport which many studentsdeveloped was of such a nature that pre­ceptors found it unwise to advise a patientdirectly after being told by several thatthe advice would be followed only if the"family doctor" agreed.

This year, although the essential struc­ture and objectives of the program haveremained unchanged, each student in thethird-year class was assigned to a patientwith a chronic illness. The patient is to befollowed during the third year only. Outof this contact it is hoped that studentswill be consulted when illness develops inother members of the family. This is, infact, the natural development of events inany family practice. It is felt that the de­gree of success in the extension of medicalcare to other members of the family willinevitably be a reflection of the relation­ship established with the assigned patient.This already has been noted as a frequentoccurrence. The advantage of the singlepatient assignment within a family unit is

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

primarily in the opportunity it providesfor the student to relate his experience inmedical care to a sharply focused respon­sibility rather than the diffuse artificialityOf a family assignment.

Three years of experience in this areahas emphasized clearly that the studentdevelops an appreciation of the need tounderstand a patient in relation to his lifehistory and total environment. He is keenlyaware of his responsibility for a humanbeing rather than a symptom or a disease.

What is visualized as an ideal goal inthe integration of a home care program inthe medical curriculum is in reality quitedifferent from that which is in operationat present. It consists of a morning assign­ment in a general medical clinic in whichthe student would function essentially asany physician in his own office. The at­tending physicians or instructors wouldserve in the capacity of consultants or ad­visors. The afternoons would be spent onthe home medical service. The studentcould thus see his patients on both an am­bulatory and non-ambulatory basis. Dur­ing this period he also should have freeaccess to the hospital wards in order tofollow those of his patients whom he hadhospitalized. It is hoped that such reor­ganization of the entire program may beinstituted in the near future.

It is probably beyond question thatwhile medical education is concerned withthe development of a high degree of tech­nical knowledge and skill, there are alsoother pertinent obligations. Medical edu­cation also should be concerned with em­phasizing in the student's experience thatthe acceptance of responsibility for thewelfare of another human being is one ofthe most significant steps in the art ofmedicine, an art in which insight andunderstanding playas important a role astechnical knowledge. It is hoped that hewill learn too that the core of good medicalpractice is and will continue to be therelationship between doctor and patient.

Dr. Jacob Horowitz: The Department ofHealth and Hospitals of the City of Denverand the University of Colorado School ofMedicine are establishing a general clinicin the Denver General Hospital. This willrepresent a joint effort to provide fairlycomprehensive medical care for the indi­gent and medically indigent of the city ofDenver and to incorporate within thisprogram the teaching of medical studentsduring their third and fourth years. Pa­tients for assignment to students will beselected from the indigent population andwill be followed as members of a family

62ND ANNUAL MEETING

unit. The staff will consist of eight full­time members in addition to voluntaryphysician teachers, a sociologist, homenurses and social service workers. Full­time members of other clinical depart­ments also will participate in this program.

The chief concerns of this reorientationof school, hospital and health departmentwill be the provision of medical care fortlJe indigent sick of the city of Denver,the further development of general prac­tice internships and the institution of adomiciliary medical care program.Throughout this coordinated project is thecareful integration of education at thegraduate as well as undergraduate level inthe various aspects of medical care.

The problems which have developed arcmany and varied and .include the mattersof staffing, physical facilities and records.The staffing of the Denver General Hospi­tal in respect to the divisions of preven­tive medicine and public health is con­cerned with the integration of a full-timestaff of internist, pediatrician, psychiatristand general practitioner. Two types ofgeneral practice residencies are develop­it~: a two-year program which will pre­pare men for community practice, and atb:'ee-year program directed at rural prac­tice.

The home care service will complete thepicture of the hospital as the general prac­titioner for the indigent of the city of Den­ver. Medical care will be provided in thehospital, the general clinic of the outpa­tient department and the home of thepatient.

SUMMARY: The lively participationand keen interest from the floor helped toemphasize certain specific factors in re­spect to medical teaching with the am­bulant patient. It appeared generallyaccepted that the student must not onlyparticipate, but must also assume a signifi­cant degree of responsibility in the provi­sion of medical care as an important stepin the development of his ability to arriveat a better understanding of the sick per­son. He must also be provided with anappreciable degree of continuity in orderto have an adequate learning experience.The feeling was unanimous that the qual­ity of education in this ~ea is directly re­lated to the quality of the teaching staff.It was, therefore, quite apparent that thesenior staff must assume responsibility forteaching and medical care on the ambu­lant as well as the hospitalized person. Inthis sense it became quite clear that theambulant patient referred to the non­hospitalized patient, rather than the am-

87

ao<.l:11::(1)

a8o

Q

bulatory person. The need to integratevarious clinical departments in the accep­tance of responsibility for the comprehen­sive experience under-discussion was onlytoo obvious.

It was pointed out that perhaps one ofthe most significant techniques in medicaleducation in this country has been theclinical clerkship. It was generally ac­cepted that the objectives of this roundtable were concerned with the expansion,development and extension of this tech­nique into the outpatient department andthe home of the patient. Beyond any ques­tion is the desirability for the physicianto understand the sick person in relationto his environment and total life history.

It would be unwise and disturbing, how­ever, to close this discussion without clearlyindicating an element of potential danger.The use of the outpatient department andhome care as a facility in medical educa­tion has been visualized for many years.Development in this direction has beendelayed by certain extensive and essen­tial preliminary steps necessary to elevatepresent teaching on the ambulant patientto the level of that attained on the ward.This will require additional financial sup­port obtainable only with great difficultyfrom existing budgets. In the last analysis,therefore, programs in this direction stillmust be tentative until the excellence ofexample is possible.

Round Table 4Group Practice in Support of MedicalEducationA. C. Furstenberg. chairman.

The rather abstruse subject of grouppractice in support of medical educationperhaps needs interpretation. Briefly, thecommittee who arranged the program forthis panel felt that many group practicesprovide opportunities for instruction ofundergraduate students and that ways andmeans should be found for making thissource of teaching material available tomembers of our senior classes. There wasalso an implied, if not an expressed, in­ference that group practice might be con­sidered from the point of view of an idealway of practicing medicine. This discus­sion, therefore, deals with two issues:first, the feasibility and practicability ofusing group practices and group clinics tosupplement or augment the teaching pro­grams of medical schools, and second, anappraisal of group practice as a means ofrendering medical service. The questionwas raised, "Are we missing a good op-

88

portunity by not utilizing these groups forundergraduate medical education?"

A rather free discussion of this topicgave expression to the belief that medicalschools perhaps are missing two importantinfluences in medical education by notaffiliating with private medical groups:first, acceptable teaching facilities of acharacter not usually encountered in amedical school, and second, the introduc­tion of the undergraduate medical studentto a form of practice which may be mostsatisfying from the standpoint of serviceand an opportunity for his own develop­ment, as well.

In respect to the first appraisal, namely,facilities for medical education, it was feltby some of the discussants that in many ofthe large clinics superior facilities 'existfor perfecting what one may term thetechnical aspects of the care of the sick.This opinion was based chiefly on the fol­lowing factors:

1. Well-balanced departments with acertain level of professional accomplish­ment are an absolute requirement. In thisconnection, representatives from a few ofthe large clinics reported that a third oftheir clinicians had extensive teachingexperience in medical schools and thatthey were well prepared to d~al withpedagogical problems throughout a widerange of medical subject. Clinics in spe­cialized topics could be prepared thatwould contribute greatly to the under­graduate teaching program.

The motivation of the physicians inthese clinics was not questioned. It wasstated that they were eager to teach andthat private patients were used constantlyin a teaching capacity with'n many of theclinics for resident instruction, and thatthis program could be expanded easily toinclude small or even large groups ofundergraduate medical students. The feel­ing was expressed that these teaching ca­pacities should not be allowed to remainlatent, but that mechanisms should be setup to utilize them by our undergraduatemedical schools.

2. The second influence of group prac­tice upon the undergraduate medical stu­dent, namely, his indoctrination into asatisfying way of professional life, broughtforth much discussion. It was argued thatan association with a clinic, even for abrief period, probably would clear up cer­tain misconceptions which seem to be heldnow by many undergraduate students andwhich necessarily influenced them to se­lect the individualistic form of medicalpractice.

MINUTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8oQ

These misconceptions would be elimi­nated by:

1. An awareness of the fact that manyof the large clinics are NOT organized forprofit, but that excess earnings are usedto improve facilities for the care of thepatient and to promote research.

2. Demonstration that the patient-phy­sician relationship can be preserved in amost intimate manner within a grouppractice framework. It was pointed outthat in most of the clinics a patient isassigned to a physician who is responsiblefor his guidance along the route of clinicalstudies. The patient may be transferredfrom one physician to another, but thereis always one doctor responsible for theindividual's welfare, who provides a sum­mation Of professional opinions, a diagnos­tic evaluation and therapeutic recommen­datiQIls. The misconception that patientsin a clinic are placed on an assembly lineand run through on a mass-productionbasis would be promptly dispelled. Thestudent would observe that proper regardfor personal problems is constantly inevidence. He would learn that there is nostandardization of diagnostic methods oroperative procedures. On the contrary, theclinic physician, it was argued, often hasgreater freedom of thought and actionthan staff members who are practicing ina medical school affiliated hospital.

3. Experience which would dismiss fromthe student's mind the impression thatresidents and fellows in clinics often areemployed as high-grade professional serv­ants who are expected to carry the loadof routine work but offered little in theway of an educational experience. It wasemphasized that in many of the largeclinics a high percentage of staff men aresincerely interested in teaching the resi­dents and fellows entrusted to them, andare most active in preparing teaching con­ferences, seminars and technical demon­strations. The feeling was expressed thatone often sees a much closer relationshipbetween the resident or fellow and hissuperior officers than is observed in manyof the large teaching hospitals affiliatedwith medical schools.

4. Observing that a clinic provides anexcellent service to the public in offeringmodern medical care to many persons inthe surrounding areas. The student wouldnote also the advantages for members ofthe medical profession in the neighboringregion who have at their disposal the com­bined clinical, scientific and physical re­sources of the clinic for consultations,diagnostic and therapeutic measures. Many

62ND ANNUAL MEETING

of the groups in the south and middle westextend their services beyond the walls oftheir offices into the homes of neighboringresidents. To do this they add generalpractice physicians to their staffs. 'Thus,they would seem prepared to offer sometraining in the general practice of medi­cine to undergraduates, a phase of educa­tion which is alleged to be woefully lack­ing in many of our medical schools today.

In general, it was felt that the seniormedical student, confronted with the needof selecting group practice or solo practiceto which he will devote his life, wouldprofit by an experience with group prac­tice. He would become acquainted withthe resources and physical facilities ofgroups, their specialized skills, superiorqualifications and the favorable economicconditions under which they were offeringtheir services. A familiarity with the his­torical development of the clinic alsowould acquaint him with the fact thatwhile there still exists some resistance togroup practice, evolutionary changes inmedicine are obviously rapidly breakingthis down. He would learn that he couldhave the professional, intellectual and eco­nomic advantages of group practice with­out fear of derision from his professionalcolleagues.

In conclusion, it was generally agreedthat:

1. Group practice offers a valuable edu­cational facility of a variety not alwaysfound in a medical school affiliated hospi­tal. The student might profit through utili­zation of these facilities, but not at theexpense of depriving pim of any impor­tant part of the regular curriCUlum. TheWisconsin plan of a 48·week instead of a36-week senior year wa$ recommended forthose students who ar~ to be farmed outfor a one-quarter period to group practice.

2. That while indoctrination into grouppractice as a way of life\might be desir­able, it could, however, bt deferred with­out disadvantage until thf period of post­graduate study.

Round Table 5The Influence of Medical Care InsurancePlans on Teaching MaterlafLoren Chandler, chairman/'

Some of the facts pres~nted and conclu­sions reached by the pa*l were:

1. The indigent, medifally indigent andlow income groups incltJde approximately80 per cent of our population. This groupalways has made up a large part of theteaching cases in our mlrlical schools.

89

I

ao<.l:11::(1)

a8o

Q

2. Approximately 76 million of our pop­ulation now are covered by hospital insur­ance, approximately 29 million have in­surance including surgical care benefits,approximately 18 million have insuranceincluding medical care benefits.

Five per cent of the population are richenough not to need medical care insur­ance.

Ten per cent of the popUlation cannotafford the premiums of comprehensivemedical care insurance.

Eighty-five per cent of the populationare candidates for comprehensive medicalcare insurance.

Insurance carriers do not care who pro­vides the medical service as long as theindividual or group is professionally com­petent.

3. An institution cannot legally practicemedicine, hence the necessity for organi­zation of the faculty to make it legallyable to accept patients for care and acceptfees for professional services rendered.There are various ways of doing this.

Once a physician group or faculty ac­cepts a patient, it becomes ethically andlegally responsible for the care of thatpatient at home, 'in the clinic or in thehospital.

4. The insurer will pay for services ormedical care but not for exhorbitant hos­pitalization costs, extra laboratory tests,research on patient~, etc.

5. The use of pay patients for teachingpurposes on a voluntary basis is possibleand feasible.

Most insured patients are willing to en­ter teaching wards or services.

Teaching services made up entirely ofpay patients may be quite adequate forundergraduate instruction, intern trainingand training in the nonsurgical specialties.

Pay patients are inadequate for surgicaltraining because the trainee must havefull responsibility for the management ofhis cases including the operation.

6. In one stu:ly, the quality of medical- care of patients treated by a medical schoolgroup was found to be superior to thequality of cale provided by individualphysicians in the same community.

7. The time spent by the faculty in theclinical departments rendering prepaidmedical care was found to be greater thanthe time spent lIy most full-time or geo­graphic full-time faculties, but less thanthe time spent bt' volunteer faculties.

8. Medical scrools must have enoughclinical material out must avoid taking toomuch. Health inrurance plans provide oneway of getting Enough. .

90

9. The Association might well requestthe practicing medical profession to referpatients in sufficient numbers to fill theclinical needs of our various medicalschools.

Round Table 6The Means of Appraisal of the MedicalStudent's Progress and of the Effectivenessof TeachingRobert Moore, chairman.

In planning for the panel it was decidedthat the "Appraisal of the Medical Stu­dent's Progress and of the Effectiveness ofTeaching" could not be discussed withoutsome preliminary consideration or condi­tions which are essential for effective in­struction.

It was agreed that the school shouldcreate an environment in which a studentmay develop as a truly educated personand not just as a recipient of facts. Fur­ther, \re should bear in mind that the ~tu­

dent has come to medical school primarilyto learn to be a physician and not to be aspecialist. Each subject should be fittedinto the whole.

One of the most important techniques increating this environment is intimate con­tact between faculty and student as exem­plified in small group teaching. The teach­er should develop in the student theability to think, not just memorize facts.Some question was raised on the full utili­zation of brilliant teachers in small groupswith the inevitable result that others donot or cannot benefit from his brilliance.

The courses in psychiatry can not onlygive the student knowledge, but also canbe taught in such a way that the studentbecomes aware of personal problems-hisown and others. It was emphasized thathelp to the student in his personal prob­lems must be completely separated fromthe administration of the school. The stu­dent must know that there is a sharp de­lineation of these problems from grade,discipline and other items associated Withthe dean's office.

There was a consensus that the exami­nation should be a part of the educationalenterprise and not just an instrument ofthe devil to torture him and come up witha grade. An examination may be a teach­ing instrument.

Examinations may and should servemany different purposes. They may indi­cate when the educational process is com­pleted. They may be used to improveteaching. They may be useful in helpingthe student if careful evaluation and anal­ysis of the examination show deficiencies

~UTES OF THE PROCEEDINGS

ao<.l:11::(1)

a8o

Q

In certain mental processes or skills. Theymay give information on how much prog­ress has been made between two timepoints. For example, an examinationmight be given on the first day of a courseto serve as the base point.

The preparation of anyone of the dif­ferent means of appraisal is a joint enter­prise between content and design or be­tween substance and form. To develop anadequate examinatien the objectives ofthe entire educational goal and of the par­ticular fragment under consideration mustbe defined. In an examinatron, materialmay be used beyond that required to ar­rive at a grade.

The idea. was expressed by some thatexaminations might be abolished or atleast made voluntary. Thus, examinationsbecome a means for the student to test hisprogress, not for the faculty to assess hisknowledge.

The relation of schools to state boardexaminations was discussed by severalparticipants. The consensus seemed to bethat they are a part of our society and thatschools must bear them in mind, but thatfear of them should be dispelled by thefaculty and by pointing to the good recordof previous graduates.

The discussions in this panel may besummarized as follows:

1. Medical schools should be conductedin an atmosphere which will lead to thematuration, emotionally and educationally,of the individual.

2. There are many different means toappraise progress in the maturation.

3. One of the most satisfactory meanscomes from an intimate relation of studentand faculty in small group teaching.

4. Examination should be a part of theeducational process and, therefore, teachas well as appraise.

ResolutionsFour resolutions were presented on

Wednesday, October 31:I. The following r~olutionwas present­

ed by Dr. Ward Darley and was unani­mously passed:

WHEREAS Dr. Arthur C. Bachmeyer isa medical educator and administrator ofnational and international note, and

WHEREAS he has served the Associa­tion of American Medical Colleges ablyand devotedly since 1925-notably as amember of the Executive Council in 1932­33, treasurer from 1935 to 49, president­elect in 1949-50, president 1950-51, andthroughout this period as a valuable mem-

62ND ANNUAL MEETING

ber of innumerable committees and as arepresentative of the Association at count­less conferences and meetings,

HEREIN BE IT RESOLVED that theAssociation of American Medical Collegesin assembly at French Lick, Indiana, this31st day of October, 1951, directs that anexpression of deep appreciation be en­tered on the records of its transactions.

2. The following resolution was pre­sented by Dr. Hugh Wood and passed bya vote of 30 to 18:

The concern of many of the deans andfaculties of medical schools having rela­tionship with Veterans Administrationhospitals, over certain aspects of the oper­ation of those hospitals, has been ex­pressed in the discussions of various com­mittees and groups of this meeting.

Medical care for the veterans is unsur­passed; we must keep it that way. Thepresent high quality of this medical careis the result of the cooperation of therespective dean's committees and the fac­ulties of the medical schools. First, thehospitals have been so well staffed thatthe professional work has been excep­tionally high quality. Second, the residenttraining program in these hospitals hasbeen so good that increasing numbers ofcompetent young doctors have wished forpostgraduate training in these institutions.

We believe that this combination of ex­pert professional care and high-type resi­dency training has made the service of theVA hospitals so desirable and so popularthat increasing numbers of veterans havewished to be cared for in them. We know,of course, dean's committees and theirfaculties feel strongly that the very bestof medical care should be preserved forveterans in accordance with the laws thathave been enacted by Congress. On theother hand, we also believe that the useof VA facilities for veterans with non­service-connected illnesses and disabilitieswho are, by any reasonable definition,able to pay for adequate medical careshould not be permitted. The use of vet­eran facilities in such manner we believeto be great at the present time, and grow­ing. As a consequence of this it will be­come overwhelming and will threaten todestroy the high quality of medical carethat dean's committees and their facultieshave made possible for veterans.

This Association calls this matter to theattention of the various dean's committeeswith the suggestion that they give theirearnest consideration to this threat to thecontinued provision of high quality med­ical care and the related educational pro-

91

ao<.l:11::(1)

a8o

Q

gram. This Association recommends to thedean's committees and their faculties thatthey make an investigation of this situa­tion and take appropriate action designedto correct it, thus insuring for needy vet­erans the best possible care. They deserveno less.

3. The following resolution was present­ed by Dr. Stockton Kimball and unani­mously passed:

Be it resolved that the Association ofAmerican Medical Colleges, in d>opera­tion with the American Medical Associa-

92

tion Council on Medical Education and thefederal services, study methods for imple­menting the previously approved curri­cular recommendations of the Joint Com­mittee on Medical Education in Time ofNational Emergency.

4. The following resolution was unani­mously passed:

The Association of American MedicalColleges wishe.s to express its appreciationfor the fine hospitality provided it by theFrench Lick Springs Hotel and its staff atits 62nd Annual Meeting, October 29 to31, 1951.

MINUTES OF THl: PROCEEDINGS