association of american medical colleges selected topics

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e AAMC Not to be reproduced without permission

Association of American Medical Colleges

Albert Einstein College of Medicine

Fall, 1986

Volume 2

Issues in Student Affairs Dr. Jean Cook page 1

Improving Basic Science Education Dr. Albert Kuperman page 2

Selected Topics Dr. Elizabeth ICachur page 3

Medical School Admissions Noreen Silverman page 4,

Improvements in Teaching Medicine Dr. Martin Levine page 5

Higher Education Amendments of 1986 Dr. Robert Petersdorf page 6

Medical Education and Health Services Research Robin Kupfer page 7

Personal Anecdotes on the AAMC National Conference Cirecie West page 8

Humanism in Medical Education Seth M. Rubin page 9

Problems in the Residency Selection Process Bradley Mackler page 11

Ominous Trends in Medical Care Delivery Mackler, Rubin page 12

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Editor's Note:

The Association of American Medical Colleges (AAMC) is the primary representative body ofmedical schools. The AAMC provides a forum for the discussion of important issues and thepresentation of innovations in all areas of medical education. Einstein is well-represented at theAAMC, including two representatives to the Organization of Student Representatives (OSR); BradleyMackler, Class of '88, and myself.

The new format of the AAMC Update includes articles authored not only by students, but also byfaculty and administration members. The goal of this journal is to keep Einstein students abreast ofissues in health care delivery and medical education. Medical education is extremely demanding, andstudents often lose sight of these broader issues.

This is the first attempt at this type of collection. No doubt improvements can be made. Brad andI look forward to your constructive criticism and feedback. We can be reached at:

Bradley Mackler, Belfer Box #92ASeth Rubin, Belfer Box #477

I wish to extend a special thank you to the following people, without whom this journal wouldnever have been possible:

Ms. Bunny BellDr. Jean CookMs. Donna GerardiMr. Lloyd GreenbergDr. Albert KupermanThe staff of the Kennedy Computer Center

Sincerely yours,

Seth M. Rubin, Class of '89Editor, AAMC Update

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Issues in Student Affairs

Jean L. Cook, M.D.Associate Dean for Students

As usual, I spent most of my time at the1986 Annual Meeting of the Association ofAmerican Medical Colleges in New Orleansattending sessions of the Group on StudentAffairs.

I attended an interesting panel discussion on"Student Advocacy vs. InstitutionalResponsibility." This was an opportunity forDeans of Student Affairs to share theirguidelines for playing their necessarily dual role:that of advocate for individual students, andprotector of society against the graduation ofimpaired students.

A panel discussion with the Director of asurgery residency program was verydiscouraging. The Director said his problemwas to fill eight PGY-1 (First Year Resident)slots for five-year general surgery training,selecting from more than 400 applicants. To dothis, someone in his office reads and evaluatesthe last paragraph of the Dean's letter, sifts outapplicants who describe no research experience,and passes over Pass/Fail/Honors transcriptswhich do not show Honors in surgery. Thisarbitrary process was roundly booed by thestudent affairs officers, as you may haveguessed.

In everyone's mind was an awareness ofthe decline in the number of applicants tomedical school. Between 1981 and 1985, theNortheast group of schools experienced a 13%decrease in the size of its applicant pool. TheNational pool declined 10% during this period,and as a result the applicant/acceptance ratio hasdecreased. Some medical schools believe thatthe decrease in the applicant to acceptance ratiohas resulted in the consideration and acceptanceof applicants who previously would not havebeen competitive for selection at these

institutions. In a presentatiOn of their findings,Drs. John B. Molidor and Cynthia Tudorconcluded that to date there had been noobservable declines in the quality of the nationalapplicant pool as measured by MCAT scoresand GPA's.

At the Business Meeting of the Group onStudent Affairs, the presentations and"business" discussions were rather dull; but thetheme was one that has been with us for the lastfew years in one form or another: Thepre-residency syndrome, and the fact that theNational Residency Matching Program (NRMP)needs to be changed. It is important that NRMPbecome attractive to the training programs whichnow ask students to submit early Dean's Lettersand transcripts. In this case "early" is before theclerkship year ends in most medical schools.

The NEGSA (Northeast Group on StudentAffairs) Executive Committee met in Neworleans to plan the April 1987 regional meeting,which will be held in Boston. One item oneveryone's mind was the decline in the numberof medical school applications, so the theme inBoston will be "The changing applicant pool anda changing profession: Implications for thefuture of Medicine." Two of us in studentaffairs will be putting together some workshopsfor the April meeting on 1) Counseling theMarried Student, 2) The Counseling/AdvocacyConflict, and 3) Racism, Sexism, and OtherDiscriminations in Medical Schools.

I would appreciate any ideas Einsteinstudents may have about these topics as we goabout planning the workshops. Thanks inadvance for your help.

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Improving Basic Science Education

Albert S. KupermanAssociate Dean for Educational Affairs

This AAMC Update is a wonderful ideaand a good example of our students' interest inthe process of medical education. I am delightedto have the opportunity of contributing to thesecond edition.

There is a well established tradition atEinstein of encouraging medical students to playan active role in curriculum planning, thedevelopment of new programs and theimprovement of old ones. Students have beenespecially helpful in maintaining a congenial andsupportive environment for learning and inestablishing programs to neutralize strains andstresses. I certainly applaud the students'success in injecting a large dose of humanism •into the academic program, and efforts in thisdirection must continue.

As usual, the annual AAMC conventionoffered a wide range of ideas about medicaleducation. The recent report on "Physicians forthe Twenty First Century" was a stimulus tomany of them and is a springboard for newprograms at medical schools across the country,including one in the Bronx. Many of theseprograms focus on changing the nature of basicscience instruction, and it is this issue that Iwant to address.

Year after year, I am an unhappy witness tothe unreasonable demands that a compressedand fast-track preclerkship curriculum makes onstudents. Information overload, the excessiveuse of the lecture as a mode of teaching, theemphasis on fact acquisition and recall, the lackof clear learning objectives, the poor quality ofmany examinations - all these and morecontribute to student dissatisfaction. In order tosurvive, many students rely on old examinationsas primary study aids and are content to slipthrough the wide pass window in basic sciencecourses. A philosophy of minimalism has creptinto students' attitudes and work habits.Considering the nature of the preclerkship

learning environment, this behavior may beviewed as rational and appropriate. After all,almost all students do pass the basic sciencecourses and are promoted to the clerkship year.

Unfortunately, the type of coping behaviordeveloped during basic science courses can haveadverse effects on students' clinical education.With the continuing explosion of knowledge inmolecular biology, good clinical practice is morestrongly linked than ever to basic scienceinformation and to the use of that information inmaking sound clinical decisions. Thus, ajust-passing approach to basic science courseswill simply not suffice.

So much for the diagnosis and prognosis;what is the treatment? My own recommendationis in line with current conventional wisdom.Basic science learning must shift to one that isproblem based with plenty of opportunity forindependent, self-directed activities. We mustshift from( the information storage/retrievalapproach to one that focuses on the applicationof information to problem solving.Furthermore, clinical education must build onthese new approaches and focus more on thecognitive skills of clinical reasoning anddecision making. Finally, our examinationsshould assess problem solving rather thaninformation recall capacity.

This recommendation is not revolutionary.It is based on an abundance of good educationalresearch, the ideas and wisdom of manyfirst-rate educational theorists, and the actualexperiences of a few medical schools that havealready departed from the traditional. So muchfor the good news.

The bad new is that a problem-based learningcurriculum is very demanding of faculty time. Itis never easy to make drastic changes incurriculum, which is why we prefer to tinkerand fine-tune. It is even harder to do while


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simultaneously operating a large and complexresearch engine and providing good patient carein an already hard-pressed hospital environment.Also, our incentive-reward system does notencourage faculty to undertake major neweducational responsibilities.

I am convinced that not too many yearsaway, the best and brightest applicants will flockto those medical schools that have made thegreatest progress towards adopting the newways of teaching and learning. If I am correct inthis assumption, and in view of the shrinkingapplicant pool, we will need to change at a fasterrate than we would like. Our very survival as agreat medical school is at risk. The faculty,students, administration - all working together,must find a way to overcome the obstacles toeducational change.

I welcome the advice and support of studentsin changing the approach to teaching andlearning of basic sciences with the goal ofmaking the preclerkship experience morepositive and productive. We may never see theday when students regret leaving the basicsciences to go on to their clerkship rotations; butwe may change things in a way that all studentsreally understand and appreciate the role ofbiomedical sciences as a foundation for clinicaleducation and practice. When that day comes, Isuspect that students will •abandon thejust-get-through approach and deal with basicscience courses as energetically and creatively asthey deal with their clinical activities.

Selected TopicsElizabeth Kachur, Ph.D.

Coordinator, Introduction to Clinical Medicine

The Change in Health Care - How Does itEffect Medical Education?

Advancements in medicine made it possible to diagnoseand treat more disorders in an ambulatory setting, whichinitiated a major shift from inpatient to outpatient care.Changes in insurance reimbursement procedures, DRGs(Diagnosis Related Groups), added to this trend, whichresulted in a hospital population that is sicker and has ashorter stay. Overall medicine is moving from"non-profit" to "for-profit," with a steady increase inHMOs (Health Maintenance Organizations) and otherstaff/group practices. Approximately 12,000 physicianswork in such settings now and it is projected that in acouple of decades, over 90% of the health care will beprovided by corporations.

As a result of the above changes, medical schools andresidency programs have to provide more training inambulatory care. Teaching in these settings is usuallyon a one-to-one basis which increases the expense.Many clinics are not eager to get "entangled" with

medical schools and some programs have to pay forstudent training. Other schools have bought outpatientsettings such as HMOs or have taken over health careservices in neighborhood clinics, schools and prisons.

Home health care is another delivery system that isexpanding, and AECOM has piloted a program where 29fust-year students accompanied a health care provider to apatient's home. The testing phase of this project willcontinue this year and hopefully with the start of theIntroduction to Clinical Medicine (ICM) course in1987-89, all first year students will get an orientation tohome health care.

Clinical Skills Assessment - How Valid andReliable Are They?

Major efforts are underway to develop methods thatwill accurately measure clinical skills. The objectivestructured clinical examination (OS CE) has beenintroduced, and more schools are trying it. (Studentsrotate through a standard set of "stations." Each station


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poses a different clinical problem on which the student isevaluated by an observer.)

Many educators agree that OSCE's are worthwhile, andcertainly can be utilized as an evaluation instrument orteaching exercise. In order to make OSCE's an integralpart of evaluations, research has to find answers toquestions such as: How many stations are needed? Whatkind of skills can be tested? How do OSCE's comparewith conventional evaluation methods; grades, NBME(boards), patient feedback?

Last year, AECOM was the first New York school topilot an OSCE in the physical diagnosis course: 25students rotated through 25 stations. This year, a similarexercise is planned, which should involve most, if notall, sophomores. Since it will be a teaching exerciserather than an evaluation instrument, it has been named"GOSCE" (group oriented structured clinical exercise).Watch for it!!

Content Versus Process or Knowledge VersusSkill

What factors determine success or lack of success in

medical student and physician performance? Whileknowing the facts is important, more attention has to begiven to how these facts are accumulated and how theyare used. Study skills -- which include reading andthinking skills -- cannot be remedied by just going overthe material (content tutoring). It must be noted thatpoor diagnosticians tend to decode fewer signs andsymptoms, ignore predisposing factors, and jump topremature conclusions.

Such findings should bring about changes in the designof tutorial programs. Learning, critical thinking andproblem-solving seminars may be of benefit to all.Although such endeavors require time to implement, inthe long run they are bound to save time by increasingaccuracy and productivity.

Content/process dichotomy is also an issue inteaching. Although there are few schools who haveproblem-based curricula, medical education is clearlymoving away from overloading students in lecture hallsto "hands-on" experiences, small group teaching andindependent learning. Faculty development efforts havestarted to prepare teachers for this change

Medical School AdmissionsNoreen Silverman,

Admissions Officer

One of the major problems facing medical schooladmissions persons in these days of decliningapplications is the shift of applicants from one school toanother in the months just prior to Septemberenrollment.

The AAMC discussed this problem at length in NewOrleans. The key concern was allowing applicantsenough time to decide on which school to attend, whilealso allowing enough time for schools to fill placesvacated by applicants. The problem lies in the fact thatthe two situations cannot exist, presumably,simultaneously.

A few suggestions were made to alleviate the problem.By May 1 or earlier, schools must offer enough places tofill their classes. By June 1, schools may require thatapplicants holding places in their classes do not holdplaces at other medical schools. After July 1, schools

desiring to make an offer of admission to a studentholding a place at another school may do so only afterconsultation with that school. The two schools mayagree upon a date whereby the applicant will be holdingonly one place. The time period for this decision shouldnot exceed one week. Furthermore, accepted applicantsshould be given a preliminary estimate of financial aidnot later than June 1 if their needs analysis form andother required documents have been received in themedical school financial aid office by May 15.

The concern expressed by GSA members regarding theabove suggestions centered on the assumption that once astudent receives the acceptance of choice, he/she willrelinquish all other acceptance and wait-list offers. Thesuggestions fail to take into consideration the applciant'sego and desire to know just how far the fruits of one'sthree years (or more) of labor will take him/her.Understandable!

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The chances that an offer of acceptance will be made toany given student this year are better than any other yearsince 1981. Applications are down, while the number offirst-year places holds constant. More offers ofadmission will be made this year than in the last sixyears. Students will be under great pressure from schoolsto make up their minds quickly so that the schools mayrest assured that their places will be filled.

The GSA (Group on Student Affairs) also discussedage-old problems such as preadmission requirements andthe need (or lack of need!) for the MCATs. It sought toencourage the development of guidelines to assessnon-cognitive indicators of applicants' characteristics andlooked at the characteristics and changes innon-traditional applicants over time

Improvements in Teaching Medicine

Dr. Martin G. LevineDirector, Audio Visual Center

Instructional technology, educational methodsand teaching effectiveness are my specificinterests both at Einstein and at the AAMC.

Following a Sunday morning meeting of theAssociation of Biomedical CommunicationsDirectors, I participated in a GME (Group onMedical Education) workshop, "Evaluation andRewarding Excellence in Teaching in MedicalEducation Programs." The workshop,organized around a "Self-Management Model"by Dr. Howard Stone (University of WisconsinMedical School), discussed evaluation in uniqueorganizational settings, means to rewardteaching effectiveness and alternatives fordealing with ineffective teaching. His modelrequires establishing an "effective relationship,"whose components are knowledge, skills andthe effective use of "self" ... human warmth,spontaneous concern and immediate responseand feedback to patients or students. Whileunique in placing the responsibility on theindividual instructor, this approach joinsnumerous others presented over the years. Mosthave not succeeded due to lack of more thanverbal support.

The next day, the morning plenary sessionincluded several major presentations, thoughhighlighted by one given by the Chancellor ofSUNY, Dr. Clifton Wharton, who provided aunique perspective on the challenges of diversityin medical educational leadership. The

innovations in medical education exhibits, in theafternoon, as usual, provided a wealth ofapproaches by individuals and institutions toproblems faced at many schools by faculty,students and program directors in the generalcurriculum and particular courses.

Due to time constraints, my greatest attentionat the exhibits was drawn to approaches thatspanned immediate areas of interest, e.g.,Computerized, Tomography learning modulesfor anatomy and the integration of educationalvideo into the teaching of basic sciences in atraditional medical curriculum. The first, forexample, has potential in an interdisciplinary,self-directed, problem based learningenvironment, whereas, the latter as a means toenhance teaching effectiveness.

This year included an ever-growing number ofexhibits on computer applications in medicaleducation. This ranged from level II interactivevideo for "socratic" style instruction in coursesdealing with largely visual subject matter to largeinteractive video data banks for diagnosis andtraining.

The remainder of my day and conventionincluded the Group on Medical Educationregional and national meetings, for I had a lateplane to catch and gross lab the next morning.


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Higher Education Amendments of 1986'Robert G. Petersdorf, M.D.

PresidentAssociation of American Medical Colleges

President Reagan has just signed into lawP.L. 99-498, the "Higher EducationAmendments of 1986." This five year revisionand extension of the Higher Education Act(HEA) will have profound and generallybeneficial impact on all of the HEA studentfinancial assistance programs that are heavilyrelied upon by medical students.

STUDENT FINANCIAL ASSISTANCE

Guaranteed Student Loan

The annual GSL maximum for graduate andprofessional students is increased to $7,500, and theCumulative GSL borrowing limit is raised to $54,750,effective January 1, 1987. The current authority for theSecretary of the Department of Education to increaseannual and aggregate GSL borrowing ceilings forstudents "engaged in specialized training requiringexceptionally high costs of education" is retained.

The interest rate for new GSL borrowers is set at 8%;after 4 years of repayment, the rate increases to 10%.This change will take effect on July 1, 1988.

Needs analysis will be required of all GSL applicantsbefore they can receive the loans as of January 1, 1987.

A One-time insurance premium of up to 3% of theloan principal will be taken out of each new GSL.Individual state guarantee agencies will determine thespecific percentage. Presently, insurance premiums aretied to the number of years remaining in the educationalcourse. Also, the present 5% loan origination fee ismaintained.

The current 2 year deferment for service in aninternship "required in order to receive professionalrecognition required to begin professional practice orservice" is retained.

The "special allowance", i.e., effective interest rate,paid to GSL lenders is lowered by 0.25% from thecurrent formula of the average quarterly 91-day T-bill rate

plus 3.5%.

ALAS/PLUS Program

The program has been divided into two: SupplementalLoans for Students (SLS) and Loans for Parents.

The maximum SLS loan, which will be available toall graduate and professional students, is $4,000, with acumulative borrowing limit of $20,000. As with thecurrent ALAS/PLUS program, the loans can be used toreplace Expected Family Contributions (EFCs) for otherTitle IV programs. This change became effective on thedate of enactment.

The SLS interest rate will be set at the average of the91-day T-bill rates auctioned over the previous 12months plus 3.75%, beginning July 1, 1987. The ratewill change yearly, but will be capped at 12%. PreviousALAS/PLUS borrowers will have the option ofrefinancing their loans at the new interest rate for aone-time fee of no more than $100. Lenders who do notprovide refiptincing must notify borrowers of otherlenders offering this option.

Loans for parents of up to $4,000 will be availableannually to the parents of graduate students, with acumulative borrowing limit of $20,000. The interestrate and other terms are similar to those of SLS.

The bill's report language states that medical residentsare eligible to receive SLS if they are enrolled in hospitaltraining programs that comply with the Department ofEducation's institutional eligibility and relatedrequirements. SLS funds will be available only to coverthose non-educational costs, i.e., living and relatedexpenses, that are not met by stipends. The report alsostates that SLS eligibility is intended for residents inprograms that charge tuition. It does not appear that anyphysician residents would qualify for such loans at thistime.

National Direct Student Loan (NDSL)Program

The program is renamed "Perkins Loans" after Carl D.


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Perkins, the deceased chairman of the House Educationand Labor Committee.

The cumulative loan limit for graduate andprofessional students is raised to $18,000, the graceperiod on the loans is extended to nine months, thecurrent interest rate of 5% is retained, and the statutorystandards on loan defaults will bar institutions withdefault rates above 20% from receiving new Federalcapital funds, while those with rates above 7.5% willreceive reduced contributions.

Loan Consolidation

The program is substantially revised and enhanced. AllTitle IV (GSL, SLS, ALAS/PLUS and NDSL) plusHealth Professions Student Loans can be included in thepackages. The interest rate on consolidated loans will bethe higher of nine percent or the weighted average of theloans to be consolidated, rounded to the nearest percent.The loan repayment span is tied to the level of anex-student's total indebtedness; however, loans not beingconsolidated can comprise no more than 50% of totalindebtedness for the purposes of determining therepayment length of the consolidated loan. Paymentschedules can be income-sensitive or graduated, butmonthly payments are to at least meet the amount ofaccruing interest.

Also, new "Combined Payment Plans" are authorized,under which borrowers can simultaneously retire HealthEducation Assistance Loans (HEALs) and consolidatedloans. The terms of HEALs are not to be altered in anyway. However, in cases where a borrower selects a lender

for a Combined Payment Plan that does not hold all ofhis or her HEALs, those held by other entities will needto be reissued. Borrowers choosing this option mustfirst contact holders of their HEALs and any Title IV orHPSL loans they wish to consolidate (or holders of loansalready consolidated) to see if the lender(s) will offer aCombined Payment Plan; and if so, use that lender (orone of a number of willing lenders). If none are offeringthe Plan, another lender may be employed.

The loan consolidation and related provisions becameeffective upon enactment.

Other Provisions

Title IV program participation agreements (madebetween the Department of Education and each institutioneligible for student assistance programs) will requireschools to certify that they have an institution-wide drugabuse program (as determined by the institution).

Additional facts not mentioned in Dr. Petersdorf sMemorandum:Starting in 1987, and retroactive for all previous

student loans, interest payments on student loans will nolonger be deductible for federal income tax. In addition,all students 24 years of age and older are automaticallyconsidered independent.

lAn abridged version of a memorandum sent to AAMCrepresentatives by br. Petersdorf, dated October 31, 1986,Memorandum #86-73.

Medical Education and Health Services Research

Robin KupferProgram Evaluator

Office of Educational Research and Evaluation

Two sessions of the Research In Medical EducationSymposia at the AAMC meeting in New Orleans were ofparticular interest to me. They addressed issuesconcerning the interaction of medical education and healthservices research. Health services research (HSR) refersto the study of health care delivery systems. Medicaleducators endeavor to assess undergraduate and graduatemedical training programs and suggest changes in thecurricula. The changes are geared to maximizing theknowledge and skills students need as physicians, in

relation to the environment in which they will bepracticing.

The first symposium on this subject, "MedicalEducation and Health Services Delivery - ForgingResearch Links," presented divergent views on if and howmuch medical educators should be involved in HSR.Two of the three panelists asserted that medical educatorsshould act as supplementary researchers in HSR because1) HSR results impact directly on present medical


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education, 2) Medical educators can provide theirperspective so that the research is properly focused, 3)Interdisciplinary interaction is important and can raiseissues that are pertinent to all involved, and 4) Interactionwould facilitate the integration of HSR into medicaleducation.

The third panelist, however, maintained that pertinentresults of HSR are disseminated adequately through theliterature and should be read, rather than collected, bymedical educators. He felt that there is a surplus of ideasfor research in medical education. Furthermore, medicaleducators should not take on projects that can be betterexecuted by researchers with expertise in other fields.

The second symposium, "The Use of Health Care Datain Medical Education," began with the following excerptfrom the Alma Alta declaration of the World HealthOrganization:

The Basic Goal of Medical Education is to educatemedical doctors so they will contribute maximally to thealleviation of the burden of illness in the population

which they serve.

According to the panelists, a major obstacle hinderingthe achievement of this goal is that students in traditionalmedical educational programs are not familiar with thereal burden of illness within a population. Some reasonsfor this were offered: 1) Use of traditional vital statistics(e.g. mortality, life expectancy), rather thanmeasurements of incidence and prevalence of healthproblems, 2) Failure to recognize non-medical diseasecausation (e.g. genetics, environmental and behavioralfactors, as well as the availability of health services), 3)Incomplete awareness of disease prevention techniques,and when and why they may not be effective, and 4)Minimal emphasis during medical education on thefunctioning and efficacy of the health care system.

Two suggestions to alleviate these problems werebetter integration of HSR results in curriculum planning,and greater exposure of students to the generalcommunity to see, first-hand, the health status of thepopulation being served.

Personal Anecdotes on the AAMC National Conference

Cirecie WestAssistant Director

Office of Special Educational Programs

Overall, I felt that the conference workshops,seminars, etc., were well planned and extremelyinsightful. I attended sessions sponsored bythe GME (Group on Medical Education), GSA(Group on Student Affairs), and GSA-MAS(Minority Affairs Section). The "buzz" words atthe conference were:•Computerized educational programming(clinical and basic science)

•Minority students (particularly in research)•Demographic changes in medicine

Recruitment Workshop

The pre-med workshop, sponsored by the AAMCOffice of Minority Affairs, was well-attended by bothstudents and medical school faculty. In addition to theAAMC information booth, two financial aidrepresentatives were on hand to provide generalinformation to students. Approximately 200 plus highschool and college pre-meds were in attendance.As a result of our summer research program, Dillard

University students were extremely excited aboutEinstein and several seniors had already submittedapplications through AMCAS for AECOM.

AAMC Plenary Sessions

The most interesting presentation came from CliftonR. Wharton, Ph.D., Chancellor of SUNY and Chairmanof the Rockefeller Foundation. Dr. Wharton spoke on"Leadership in Medical Education: the Challenge ofDiversity." Items of interest were: the non-whitepopulation; the female population; and demographics ofthe geriatric community. Proceedings of Dr. Wharton'sspeech have been ordered.

GSA/MAS Business Meeting

Dr. Voile, the newly-appointed president of the NBME(National Board of Medical Examiners), discussedanticipated changes in the examinations. The followingitems were discussed:•The establishment of two comprehensive committees


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(for Part I and Part II) to explore improvements in designof the exams-Possible changes in the exam:-Questions which bear a greater relationship to the

practice of medicine and medical school-Fewer test items-Fewer recall questions

-Other issues:-Pass/Fail-Method of reporting scores.

There was also mention of establishing acomputer-based exam for Part HI based on casesimulations (by 1989). The hopes are to develop anexam which will reflect clinical skills development.

Seminar: Admissions - The MCAT -Constructive Use or Abuse?

This program presented statistical data on how medicalschools utilize the MCAT's. The proceedings from thissession could be useful to the AECOM AdmissionsCommittee, particularly in reference to under-representedminority students. For example: 69% of the medicalschools surveyed indicated that they looked at MCATscores differently when reviewing minority applicants.

Panel Discussion: Increasing the MinorityApplicant Pool

This session presented successful comprehensivepre-med programs which link high school and college

students into pre-med networks or enrichment programs.

Office of Special Educational Programs(OSEP)

What is lacking at Einstein is a comprehensiveapproach to minority admissions and retention based onsubstantive historical data. This will probably be thetheme of the Office of Special Educational Programs(OSEP) in the current and upcoming years.

Innovations in medical education were very stimulativeand suggestions from various professionals will probablybe incorporated into OSEP programming. Items of notewere:-MEDPREP program at Southern Illinois University (for

the boards)-Minority High School Apprenticeship Program-Home Visit Project at the AECOM-Diagnosing Reading & Reasoning Problems, Universityof Missouri

-Applicant Pools; Implications for Recruitment andRetention Programs, University of Arkansas

-Student Stress and Student Attitudes, SUNY at Syracuse•The Network: A peer support system, Wayne State

University School of Medicine

I also concentrated on various committee meetings, andon solidifying rapport with pre-health advisors fromtargeted undergraduate schools. Additionally, I met withseveral applicants from the New Orleans area

Humanism in Medical Education

Seth M. RubinStudent Representative to the Association of American Medical Colleges

Class of '89

The faculty of this institution, as well as the majorityof medical schools, expends great efforts to teachhumanism. I am proud to say that based on myobservations at AAMC conventions, Einstein is at theforefront of humanistic education. On a number ofoccasions, deans and professors of other schools haveinquired, "I hear that Einstein has a wonderful emphasison humanism, tell me about it ..."

This issue is best handled with a good news, bad newsapproach. The good news is that a variety of innovativeeducational opportunities are available to Einstein

students thanks to the dedication of our professors. Forinstance, home visits have become a standard activityduring the first year, during clinical electives and theHuman Behavior Course. The home visit programduring the Human Behavior course was based on thefollowing objectives:

-Familiarize the student with home health care:What tasks are accomplished during a home visit by avisiting nurse, social worker, or physician?-Give the student the opportunity to observe the patientin their home environment


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How can the home environment influence diseasemanagement?.Give the student the opportunity to practice interviewingby performing a focused inquiry reflecting upon:Patient's understanding of illnessEffect of illness on patient's functional statusPatient's social support system 1

Furthermore, during the Human Behavior course,thought and discussion are inspired on the subjects ofcompassion, personal attitudes toward patients, and thevalue of holistic medical care. This emphasis isbecoming more apparent in other courses as well. Inaddition, the clinical curriculum offers Ethics Rounds todiscuss humanistic care of patients "in situ."

The bad news is that although these resources areavailable, most students do not take advantage of them.Many of my classmates describe humanism discussionsin the classroom as "a waste of time." The reader mightbe quick to conclude that Einstein students show anoutrageous disregard for humanism. I disagree. Medicaleducation is a severely stressful process. During thebasic science training period, the main evaluativeinstrument is the standardized examination where thestudent demonstrates his/her ability to memorize andunderstand a plethora of medical facts. With theinsurmountable workload in the traditional basicsciences, and a grading system which places a highervalue on these courses, humanism takes a distant secondin the learning priorities of students.

Unfortunately, many faculty members place humanisticeducation a distant second as well. At the recent AAMCconvention, when a series of seminars were presentedconcurrently, most faculty members of all schoolsattended seminars regarding basic science training,clerkships, and residencies, rather than a seminar entitled,"Approaches to the Development and Assessment ofValues, Attitudes, and Personal Qualities." At thisseminar, a number of programs at individual schoolswere discussed. Though differing approaches wereoffered, the main emphasis centered on cultivating themost important virtues in future physicians, namely,Integrity, Respect, and Compassion:

• Integrity is the personal commitment to be honestand trustworthy in evaluating and demonstrating one'sown skills and abilities.• Respect is the personal commitment to honor others'choices and rights regarding themselves and their medicalare.• Compassion is an appreciation that suffering andillness engender special needs for comfort and help

without evoking excessive emotional involvement whichcould undermine professional responsibility for the patient. 2

The difficulty in teaching humanism continues into theclerkships. Medical students receive their clinical educationprimarily from interns. Interns are the most overworkedmembers of the housestaff ... besides the pressures of patientcare, interns do not get sufficient sleep, are deprived of timewith their families, and receive a small income as their loanrepayment period commences. Under these circumstances,humanistit qualities are eroded from interns, the primary rolemodels of medical students.

Excessive stress not only plagues interns, but medicalstudents as well. B.N. Steenbarger, Ph.D., of the StateUniversity of New York Health Science Center at Syracuse,presented a project at the AAMC convention entitled,"Student Stress and Student Attitudes: Assessing the MedicalSchool Experience." Among his observations ofSUNY/Syracuse medical students were:

•One-third of students report daily or weekly experiences ofdebilitating stress.•Students reporting frequent stress were more likely toreport frequent anxiety, depression, and negativeattitudes.

The stressful environment of medical education not onlymakes humanistic teaching difficult if not ineffectual, butalso deteriorates existing humanistic values.

My classmates often talk of their cynicism and apathy andloss of idealism as the medical education process continues.Are these qualities reflected in medical students as they jointhe ranks of practicing physicians? Will idealism,enthusiasm, and optimism return once the stresses of medicaleducation have been survived? It is a pity that the medicaleducation process often destroys the humanistic energies ofstudents, or at least is an intermission in their cultivation.At Einstein, opportunities to cultivate these skills exist inquality and quantity, but are undersubscribed. Priorities mustbe re-evaluated and adjustments made in the educationprocess. If the adjustments are effective, humanism will addan exciting and essential flare to the daily lives of medicalstudents, rather than being a "waste of time."

'Objectives are from a memorandum by Elizabeth KrajicKachur, Ph.D., Coordinator, Introduction to ClinicalMedicine.2A Guide to Awareness and Evaluation ofHumanistic Qualities in the Internist, AmericanBoard of Internal Medicine, 1986. Though this guide waswritten specifically about internal medicine physicians, itsthemes are relevant for all fields of medical practice


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Problems in the Residency Selection Process

Bradley Mackler, Class of '88Student Representative to the Association of American Medical Colleges

Currently, there are approximately 1.3 trainingslots per U.S. medical graduate. Yet, asignificant portion of the fourth year is spent inthe quest of the "right spot." Many medicaleducators believe that this "pre-residencysyndrome" is interfering with students'aquisition of a general education.

Many problems with the residency selectionsystem were identified at the New Orleansmeetings. For example, students are forced tomake specialty choices too early, especially inprograms like Ophthamology, Psychiatry, andNeurosurgery. These specialties have earlymatches separate from the National ResidentMatching Program.' A partial solution to thisproblem was offered: moving the deadlines forthe National Match to a later date. The directorof the early match program said he would alsodelay his deadlines. For instance, he wouldpostpone requests for dean's letters andtranscripts. Though these changes are small,they would give the student more time to decideon a specialty.

National Board scores are used inappropriatelyto select among candidates. The Organization ofStudent Representatives (OSR) of the AAMC istrying to get the board scores reported pass/fail.Thus, residency program directors, especially inhighly competitive programs, would not be ableto use the boards to "weed people out" or as ayardstick to compare medical schools. Thischange will be particularly important forstudents applying to programs outside of thegeographic location of his/her school.Furthermore, the boards, with their greatemphasis on factual knowledge, would play alesser role in shaping medical education.

Students are often asked to take electives at theinstitutions to which they are applying. This isparticularly true for Otorhinolaryngology,Orthopedic Surgery, and Neurosurgery.However, the national program directors of

these specialties said that these "auditionelectives" often hurt students because theyexpose weaknesses. Nevertheless, theysuggested doing one elective in the specialty youplan to choose at the home institution and oneaway.

A strong research project is considered a bigplus for a residency applicant. The chairman ofthe Department of Surgery for Tulane Universitysuggested that a meaningful research project isoften a more profitable endeavor than auditionelectives.

Abuses of the system exist. For instance,students are at times asked to makecommitments to enter programs before the matchresults are received. This occurs relatively oftenin Anesthesiology, Psychiatry, OrthopedicSurgery, and Radiology. This is an unethicalpractice which puts students in a bind. Theseprogram directors do not allow students to hearif they got int94he program they most desired,forcing a commitment before the Match resultsare received.

Though the current system has problems, it isunlikely revolutionary changes will soon beoffered. Students will continue to face aconfusing task of quickly, if not prematurely,choosing a specialty. Furthermore, theanxiety-ridden match process will continue, andthe "preresidency syndrome" will doubtlessremain.

1Match programs work by institutionssubmitting a ranked list of students they want,and students ranking the programs they desire,with a computer matching the two. You willfind out more about this at the start of the fourthyear.


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Ominous Trends in Medical Care DeliverySeth M. Rubin, Class of '89Bradley Mackler, Class of '88

Student Representatives to the Association of American Medical Colleges

Drs. Leon and Corola Eisenberg of theHarvard University School of Medicine held atalk entitled, "The Light at the End of theMedical School Tunnel: Watch Out for Trains."They commented on the recent, dramaticchanges in the Medical Care System of theUnited States. Unfortunately, some of thesechanges may erode the excellent quality healthcare that has been the American standard.

Health Maintenance Organizations (HMOs)and Diagnosis Related Groups (DRGs), have acommon goal: to provide the minimum amountof care to a given patient. Because thehospital/physician is paid a lump sum per patient(HMOs) or per illness (DRGs), the less careprovided, the greater the profit. Patients arebeing discharged sooner, and cheaper therapy isreplacing more expensive, with a greateremphasis being placed on cost that quality.

An additional recent development is the rapidemergence of private rather than not-for-profithealth care. An example of the possibleill-effects of this change may be the HumanaHealth Care, Inc. artificial heart implantationresearch study. The primary goal of Humana'sresearch is to boost publicity. This goalestablishes a negative incentive for researchwhich may be more important in the medicalcommunity's eye, though bland to the laypublic.

Additionally, the government has reduced itscommitments to medical education. As a result,more costs are placed upon students; studentdebt figures have skyrocketed. Students are

now pursuing more lucrative careers to help payback their debt, rather than lower-paying fieldswhich may be more important to thecommunity's needs (i.e. family practice).

Many undergraduate students have beendiscouraged from a medical career as theybecome familiar with the problems medicine isconfronting. Perhaps it is the job of physiciansto also broadcast that though problems exist,medicine continues to be a rewarding field. Infact, Dr. Corola Eisenberg recently contributedan editorial to The New England Journal ofMedicine entitled,"It is Still a Privilege to be aPhysician."

Senator Thomas F. Eagleton and Clifton R.Wharton, Jr., Ph.D., Chancellor, StateUniversity of New York, emphasized thatphysicians must play a larger societal role. Thepublic is unsympathetic to physicians whocomplain that their incomes are suffering fromthe liability crisis and federal cutbacks.However, if physicians argue as patientadvocates, then the American public will bemore likely to be sympathetic to their cause. Itis not physicians who suffer most fromincreasing medical costs and decreasinggovernmental support, but the elderly, poor, anduninsured


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