129
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. BME-22, NO. 2, MARCH 1975
department. The flexibility provided by current engineering curricula at most universities should be sufficient to provide a high quality bioengineering educational opportunity. Our program has been built on the philosophical foundation of collaboration. Our experience indicates it is a highly desirable and successful approach. The engineer is expected to be fully qualified and up-to-date in his field, be it fluid mechanics, structures, chemical processes, or electronics. He brings to the team an analytical approach and techniques with which his medical collaborators have little experience. As a fully trained professional, he should be accepted as a full member of the team and function as such. But perhaps our greatest lesson in the education of professionals in bioengineering is that the life scientist can
Experience
with
learn a great deal of the physical sciences in a short time. This is particularly true if his motivation is high and the timing right in his career development. The impact of these individuals stretches literally around the world and has provided the basis for an impressive array of bioengineering activity, particularly at the University of Washington. This training coupled with appropriately educated engieers has resulted in the formation of innumerable truly collaborative teams working on a wide range of projects. It is an area that deserves greater attention. REFERENCES [1] "An assessment of industrial activity in the field of biomedical engineering " Committee on the Interplay of Engineering with Biology and Medicine, Nat. Acad. Eng., W ashington, D. C., 1971. [21 "The future of training in biomedical engineering," Engineering in Biology and Medicine Training Committee of the NIH, IEEE Trans. Biomed. Eng., Vol. BME-19, No. 2, March 1972.
a Training Program in Technology in
Health
Care
JEROME R. COX, JR., MEMBER, IEEE, RUSSELL R. PFEIFFER, MEMBER, WILLIAM F. PICKARD, SENIOR MEMBER, IEEE
DURING the last four years, Washington University in St. Louis has developed and conducted within its Interdepartmental Graduate Program in Biomedical Engineering a training program in Technology in Health Care. The health care technology -(HCT) program is complementary to our training of traditional biomedical engineers; and although it has grown larger than the traditional components, its growth has been independent and has not displaced them. This review will concentrate on the health care training, results, and experience. We will describe its origin and growth at Washington University, its requirements, the importance of in-hospital training, and most importantly, experiences of graduates, placement of graduates, and reactions of employers. First, we will give a brief description of our general philosophy of biomedical engineering training because of its important influence on the development of the HCT
program. The goal of the Washington University biomedical Manuscript received August 7, 1974; revised October 17, 1974. The Technology in Health Care Program was supported in part by Public Health Services Grant HS-00074. J. R. Cox is with the Biomedical Computer Laboratory, Washington University School of Medicine, St. Louis, Mo. 63110. R. R. Pfeiffer and W. F. Pickard are with the Department of Electrical Engineering, Washington University, St. Louis, Mo. 63130.
IEEE, AND
engineering program has been to train engineers to apply their engineering skills to the solution of problems that arise in the life and medical sciences. We have not attempted to establish a new department or an independent discipline with its own body of knowledge. As a consequence, our graduate is best described as an engineer (e.g., electrical or mechanical) who has concentrated on some restricted area of the life or medical sciences or on health care and who has had substantial training in the application of engineering expertise to that area. Our motivations for this choice have been threefold. First, we are unanimous in our conviction that technological or physical science training in depth is the most important aspect of success in the application of technology. Second, we believe that the establishment of a thoroughly formalized biomedical engineering curriculum would limit the scope of biomedical engineering to the detriment of what we now consider to be a very lively and responsive program. Third, we have yet to receive from employers either a clear indication of what they expect a biomedical engineer to be or a strong demand for biomedical engineers however vaguely defined. Principally, what we have perceived is a small but adequate market for able engineers who are adaptable and biomedically oriented and who can function effectively in a clinical environment, in an indus-
130
trial setting, or along with their colleagues trained in allied life sciences. The motivations have led to a practice that requires that the bicmedical aspects of the training come in addition to or in concert with rather than instead of the engineering training required of all graduate engineering students. Our graduate course requirements are typical in many respects, except that engineering courses are selected for their relevance, and often additional time is needed to take special biomedical and life science subjects. Our graduate thesis and dissertation requirements are also typical in that the student must meet the same technical standards set for all engineering students, but are atypical in that they are required to address in their research a biomedical problem. Over the years, the paucity of fixed departmental requirements, the diversity of our students, and our endeavors to match program to student have been such that a typical program cannot be given. However, when considering the electrical engineering graduate students who have elected to participate in our biomedical engineering program, it does seem that (1) electrical engineering electives have been concentrated heavily in the area of communication theory and digital computers; (2) mathematics electives have been concentrated in the areas of operations research and probability; and (3) life science electives have been concentrated in the physiology and neurophysiology areas. Due to a combination of historical accident, faculty interest, and government funding, our biomedical engineering program has produced students who fall into three loosely defined categories:
IEEE TRANSACTIONS ON BIOMEDICAL
ENGINEERING, MARCH i975
part of our program and the subject of this report was initiated in 1969 with the first large group of students entering in the fall of 1971. Graduates are educated to have engineering skills useful in health care delivery facilities. Many of these students are strong in the area of digital computer applications or electronics but have their training augmented by considerable practical experience. Two typical theses illustrative of the scope of the program are "Computer-Assisted Medical Questionnaire Design" and "A Computer Controlled Image Processing System for Automating the Kirby-Bauer Disc Sensitivity Test." Our biomedical engineering program has produced 54 graduates from the Electrical Engineering Department alone.' Approximately 55% of the electrical engineering graduate students enrolled in the fall of 1974 will participate in the interdepartmental program in one form or another. Table I shows data on the distribution of our current students relative to the above categories. It can be seen that the number of enrolled HCT candidates exceeds that of the BAC and EB groups combined even though our HCT program is more rigidly structured, more narrowly defined, and has a larger credit hour requirement (45 instead of 30) than the other two. Table II shows data on the distribution of our graduates relative to the nature of their employment or career activities. We can see from the table that field switching is not significant. But this observation must be tempered by two facts not brought out by Table II. First, roughly half of the graduates representing the BAC-BAC square are employed by Washington University in some clinically related capacity; this does not appear to be a "holding pattern" because their positions are relatively permanent. We believe that it does suggest that as the Medical Center computer activities grow, they continue to require additional biomedical computer experts. Second, the majority of graduates in the EB-EB square are at present continuing their education here or elsewhere and few have yet found stable employment in engineering biophysics. The HCT-HCT square in Table II is large in spite of the fact that that program has only been in its training phase for three years. Since the rate of graduation of HCT trained engineers is now considerably greater than that of the other twvo categories, and since the vast majority thus far are employed by health care delivery organizations or related industry, we feel that the HCT-HCT square will soon be very dominant. To the authors, all of whom appreciate keenly the pleasures of both the design of biomedical computing systems and the pursuit of biophysical research goals, the implication drawn from these data is unmistakable: the student demand for the Technology in Health Care Program is strong, as is that of employers for graduates of the program.
1) Biomedical Applications of Computers (BAC). This is the oldest part of our program and had its origin in the Washington University Computer Laboratories beginning in 1964. Students are well prepared in digital systems design and analysis, with special emphasis toward on-line applications of mini- and micro-computers. Their life science interests are strongly oriented toward medicine and human physiology. Typical thesis titles have been "Evaluation of Optimum and Suboptimum Processors for the Fetal Electrocardiogram" and "ARGUS, A Clinical Computer System for Monitoring Electrocardiographic Rhythms." 2) Engineering Biophysics (EB). Beginning in 1966 through the cooperation of the Departments of Electrical Engineering and Physiology and Biophysics and subsequently several other departments, these students have been trained to apply their engineering skills to the solution of problems more commonly attacked by biologists or physiologists. Their life science interests tend to lie in the electrophysiology-sensory physiology area. Thesis titles which illustrate the diversity of this program are "Measurement of Water Flux in Plant Stems" and "A 1 Approximately 75% of the biomedical engineering students have Nonlinear Model for Basilar Membrane Motion and been registered in the Department of Electrical Engineering, and since complete figures from that department are easily available to Related Phenomena of Single Cochlear Nerve Fibers." the authors, the data given below exclude students enrolled in other 3) Technology in Health Care (HCT). The newest departments.
cox
131
et al.: TRAINING PROGRAM IN HEALTH CARE
TABLE III
TABLE I
DISTRIBUTION OF PRESENT BIOMEDICAL ENGINEERING GRADUATE
STUDENTS
IN THE
DEPARTMENT
OF
BAC
EB
HCT
4
13
21
Fall Total-1974
TOTAL
Non-biomedical
EB*
HCT
Industry
Unknown
Total
BAC
9
2
0
2
4
17
EB
2
13
2
4
HCT
0
0
13
11
15
15
Trainin
Activity
Total
-- BAC
7
2
23
0
14
6
54
* For the purposes of this tabulation, a present activity in engineering biophysics is taken to be any life science related endeavor not fitting in the biomedical applications of computers or health care technology categories.
TECHNOLOGY IN HEALTH CARE The training program in Technology in Health Care at Washington University is an intensive 21-month program. The curriculum emphasizes engineering rigor and is directed toward fitting graduates for a career in applied engineering research in health care. Although the program is particularly designed for those who wish to put their training to practice immediately in hospitals, it also gives an excellent preparation to those who may elect to pursue either a doctorate in engineering or a career in industry. The objectives of the program are to provide its graduates with: 1) Graduate level competence in a traditional engineering field (electrical engineering, mechanical engineering, chemical engineering, or computer science); 2) Hospital experience in clinical engineering; the application of engineering to patient care and to hospital based biomedical research; 3) A fundamental knowledge of the technical aspects of electrical systems, hazards, and safety measures pertinent to hospitals and hospital instrumentation, as well as full cognizance of the national codes, standards, and laws that apply. 4) Fluency in the use of medical and physiological terminology; 5) Working experience with hospital information or
computer systems; 6) An introduction to hospital organization and administrative function; 7) Substantial experience working with and among hospital personnel including administrators, nurses, engineers, and medical staff. The academic requirements of the program are shown
in Table III.
Objetive
Obj ect ives Add ressed
1)
engineering subjects including special courses in Hospital Electrical Systems and Instrumentation, and Engineering Aspects of Health Care Delivery
2)
Mathematics, including a course in Operations Research
3)
Lectures in Preventive Medicine (School of Medicine) (Required of all freshmen medical students)
I
2, 4, 7
4)
Topics in Clinical Medicine (School of Medicine) (Required of all freshmen
2
2, 4, 7
38
TABLE II GRADUATE TRAINING VERSUS PRESENT ACTIVITY OF BIOMEDICAL ENGINEERING GRADUATES FROM THE DEPARTMENT OF ELECTRICAL ENGINEERING (M.S. AND D.SC. GRADUATES) Present
__auat
Graduate Credit Hours
ELECTRICAL ENGINEERING
Graduate
17 - 23
3
-
6
1, 3, 5
1, 5
medical students)
5)
A general human or vertebrate physiology course
(senior-graduate level)
3 - 4
4
Hospital administration* (Division of Health Care Administration, School of
3
6, 7
Technology in Health Care Internship (School of Engineering, School of Medicine, and selected area hospitals)
6
2, 3, 4, 6, 7
8)
Clinical Engineering Practicums 1,, II Ill
none
2, 4, 7
9)
Master's Degree Thesis
6
1, 2, 7
6)
Medicine) 7)
* Students select at least one course from the Health Care Administration Program. Relevant examples are: Health Facility Planning; Hospital Management; Seminar in Health Care Delivery; and Comprehensive Health Planning.
HOSPITAL EXPERIENCE The last three items in the list of academic requirements are not traditional classroom experience, but rather emphasize the practical side of health care technology. Most important of these experiences is the internship. During the summer between the first and second year of the program, students spend twelve weeks in hospitals and related health care facilities gaining familiarity with daily operations and the role of technology. The internship program is divided into two six-week segments, the first a highly organized sequence of visits to many facilities and the second an in-depth study of problems of a particular health care setting. During the past summer, fourteen hospitals were included in the schedule ranging from an older city hospital to a new and prosperous suburban hospital and from a research oriented medical center to a service oriented community hospital. A neighborhood clinic and two health-related companies were also included. Students generally traveled in pairs, and schedules emphasized several central topics each week. Meetings between all students and the faculty reviewed the facilities seen during the week, comparing and contrasting the variety of approaches to a central topic. The second half of the internship program contrasts with the survey nature of the first half. Each student with faculty advice selects a particular setting from among those visited earlier in the summer and engages in a detailed study of its opportunities for the application of technology. The Clinical Engineering Practicums I, II, III, noncredit subjects included in the academic requirements, provide several additional special opportunities for students
132
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH 1975
to gain practical experience. Practicum I is taken in the first semester of the program and seeks to develop skills in the use and troubleshooting of electronic equipment, in the approach to systematic analysis and calibration, as well as in acquisition of the knowledge of contemporary fabrication techniques. The primary goal is to bolster those areas that may be applicable to training duties that may be required of graduates, e.g., training of technicians. Practicum II, taken in the second semester, concentrates on the hospital physical plant. Thus far, this has been carried out through the cooperation of the Barnes Hospital Maintenance and Engineering staff. Attention is given to preventive maintenance, electrical surveys, instrumentation renovation procedures and design, and hospital specification and documentation. The goal is to prepare for effective liaison with maintenance and outside architects and contractors while simultaneously increasing inhospital exposure during training. Practicum III will be first offered in fall 1974, and is directed toward clinical experience in special facilities such as the EEG clinic, the heart station, the catheterization laboratory, the X-ray department, and the rehabilitation clinic. Students are expected to gain direct experience with the present manner of operation of clinical facilities. The final component of the academic requirements, the thesis, also provides practical experience, but in depth in a specialized area of the application of technology to health care. Thesis topics are chosen to allow the student to use his engineering tools on a real clinical problem. The theses have been strong in engineering content, as would be a regular Master's Degree thesis at Washington University. Thesis topics and work have been particularly impressive to prospective employers.
PLACEMENT EXPERIENCE
have, in addition, placed two of our EB students (M.S. level) in similar hospital positions. The placement of students required unusual effort both on the part of the faculty and on the part of the individual students. For two consecutive years a brief brochure describing the program and its objectives, a cover letter soliciting inquiries, and a stamped return postcard were
mailed to the chief administrators of hospitals throughout the United States. The first year mailing was limited to those hospitals with more than 200 beds; the second included all hospitals (about 7,000) in the United States. Approximately 80-100 inquiries resulted from these mailings each year. Upon receipt of an inquiry3, student resumes and mnore details of the program were mailed, along with answers to any special questions posed by the inquirers. In addition to inquiries by mail, many telephone inquiries (more than 25) were also received. These contacts, however, were perhaps responsible for placement of less than half of the graduates. Their personal contacts with hospitals were most effective, and word-of-mouth was next most effective. Typical questions from interested hospitals included: What is the starting salary range? (Incidentally, in 1973 it was $13,000 to $14,70Q and in 1974 $13,500-$14,850.) Can students monitor service contracts? Are graduates interested in plant engineering responsibilities? Are students knowledgeable in codes, standards, and OSHA requirements? How soon will the average medium sized hospital be forced to hire clinical engineers? In add-ition, some indicated that they were only interested in a particular kind of engineer, e.g., a mechanical engineer. The majority of returns resulting from our mailings, however, did not have any special questions. Students have elected to pursue employment leads selectively or to initiate their own direct inquiries to hospitals as the result of several factors: geographical location, size of the hospital, prospective career development, and the nature of the hospital's requirements. Several apparently genuine inquiries, i.e., those with active job openings, were not pursued by any of the prospective graduates because either the hospital was interested in a plant engineer or was not located in a geographical region of interest to the students. Although several of the students had multiple job offers, the placement required attention and was not without some anxiety. On the other hand, we estimate conservatively that we could have placed, in the past year and one half, about eight to ten more engineers than were available. Timing was a major problem: Hospitals appear to decide to hire at all times of the year, but are unwilling or unable or unaccustomed to waiting for the academic cycle. We are, however, able to report that several places were quite disappointed when they failed to attract a graduate. In any event, positions appear to be more plentiful with time, and the outlook for well trained engineers appears to be good.
The design and development of our HCT program was initiated late in 1969; and after about a year and one half of work-deliberating, designing courses and curricula, developing hospital contacts-we started a class of nine students (1971). Subsequently, we have started three additional classes: nine students in 1972, ten students in 1973 and thirteen in 1974. Out of the 41 students who have started (as of June 1974), four have terminated, fourteen have graduated, two are finishing their theses, one is a doctoral student, seven are in their second half of the program, and thirteen are in the first half. Of the fourteen graduates, eleven are employed in health care technology positions, two are employed by industry and utilize their biomedical training, and one is in non-biomedical work. Of the eleven, four graduates were hired by the Veterans Administration, two are in the army, and seven were hired by private institutions or hospital groups. Those in private organizations acquired positions at an administrative level reporting directly to the hospital or group. director or assistant director. None have been subsumed under the maintenance or plant engineering EMPLOYMENT EXPERIENCE groups. To date, in most cases the health care technology Reaction from employers of our graduates has been engineer has had, upon being hired, great flexibility and We in and of his role position. the scope defining freedom positive. They have been willing to relay their experiences
cox
et al.: TRAINING PROGRAM IN HEALTH
CARE
to other hospital administrators who are interested in exploring the possibility of a biomedical engineering staff member. They also have written letters of support for our program to federal administrators charged with policy decisions with regard to extension of the training grant program. The response from our graduates has been positive; all but one appear to be satisfied with their positions, responsibilities, and challenges. In the lone instance, the employment position lacks financial support and perhaps local interest, and is burdened by bureaucratic difficulties. A two-day meeting, eight months after the graduation of our first class, was attended by seven of the eight graduates, by all students in the program, and by all of the associated faculty. That meeting provided further insight into the needs of the hospital community, as well as an evaluation and critique of the positive and negative aspects of our program. Of special interest, we believe, is the great value that the graduates unanimously placed on the internship program. We are scheduling a second two-day symposium for all graduates (now including two classes) and all oncampus students so that we may continue to evaluate and modify our program.
133
tors: the quality of the students, the quality of their training, and the quality of their performances. All, of course, are related. Students graduating from "clinical engineering" programs must be able to compete with their contemporaries trained in traditional engineering fields. If they cannot, we feel that their ultimate impact and the number of opportunities in the health care scene will be limited and disappointing. Any compromise of the technical competence of the student is an injustice to the student, to his employer, and to the profession. To this end we believe that rigorous programs designed to train engineers rather than merely designed to attract students are required. Depth and rigor in engineering must go hand in hand with practical clinical experience to insure the growth and vigor of this new profession that links medicine and engineering.
ACKNOWLEDGMENT We wish to acknowledge the continuing support and attention of the Health Resources Administration (formerly the Health Services and Mental Health Administration). We further wish to acknowledge that the success of this program would not be possible without the superb collaboration and genuine interest of members of the CONCLUSION Washington University School of Medicine and the Barnes We feel that the future for engineers in health care is Hospital of St. Louis. The program has been further relatively bright. However, the extent to which they are enhanced by association with the staff of many other accepted and sought after depends upon several key fac- hospitals in the St. Louis metropolitan area.
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. BME-22, NO. 2, MARCH 1975
department. The flexibility provided by current engineering curricula at most universities should be sufficient to provide a high quality bioengineering educational opportunity. Our program has been built on the philosophical foundation of collaboration. Our experience indicates it is a highly desirable and successful approach. The engineer is expected to be fully qualified and up-to-date in his field, be it fluid mechanics, structures, chemical processes, or electronics. He brings to the team an analytical approach and techniques with which his medical collaborators have little experience. As a fully trained professional, he should be accepted as a full member of the team and function as such. But perhaps our greatest lesson in the education of professionals in bioengineering is that the life scientist can
Experience
with
learn a great deal of the physical sciences in a short time. This is particularly true if his motivation is high and the timing right in his career development. The impact of these individuals stretches literally around the world and has provided the basis for an impressive array of bioengineering activity, particularly at the University of Washington. This training coupled with appropriately educated engieers has resulted in the formation of innumerable truly collaborative teams working on a wide range of projects. It is an area that deserves greater attention. REFERENCES [1] "An assessment of industrial activity in the field of biomedical engineering " Committee on the Interplay of Engineering with Biology and Medicine, Nat. Acad. Eng., W ashington, D. C., 1971. [21 "The future of training in biomedical engineering," Engineering in Biology and Medicine Training Committee of the NIH, IEEE Trans. Biomed. Eng., Vol. BME-19, No. 2, March 1972.
a Training Program in Technology in
Health
Care
JEROME R. COX, JR., MEMBER, IEEE, RUSSELL R. PFEIFFER, MEMBER, WILLIAM F. PICKARD, SENIOR MEMBER, IEEE
DURING the last four years, Washington University in St. Louis has developed and conducted within its Interdepartmental Graduate Program in Biomedical Engineering a training program in Technology in Health Care. The health care technology -(HCT) program is complementary to our training of traditional biomedical engineers; and although it has grown larger than the traditional components, its growth has been independent and has not displaced them. This review will concentrate on the health care training, results, and experience. We will describe its origin and growth at Washington University, its requirements, the importance of in-hospital training, and most importantly, experiences of graduates, placement of graduates, and reactions of employers. First, we will give a brief description of our general philosophy of biomedical engineering training because of its important influence on the development of the HCT
program. The goal of the Washington University biomedical Manuscript received August 7, 1974; revised October 17, 1974. The Technology in Health Care Program was supported in part by Public Health Services Grant HS-00074. J. R. Cox is with the Biomedical Computer Laboratory, Washington University School of Medicine, St. Louis, Mo. 63110. R. R. Pfeiffer and W. F. Pickard are with the Department of Electrical Engineering, Washington University, St. Louis, Mo. 63130.
IEEE, AND
engineering program has been to train engineers to apply their engineering skills to the solution of problems that arise in the life and medical sciences. We have not attempted to establish a new department or an independent discipline with its own body of knowledge. As a consequence, our graduate is best described as an engineer (e.g., electrical or mechanical) who has concentrated on some restricted area of the life or medical sciences or on health care and who has had substantial training in the application of engineering expertise to that area. Our motivations for this choice have been threefold. First, we are unanimous in our conviction that technological or physical science training in depth is the most important aspect of success in the application of technology. Second, we believe that the establishment of a thoroughly formalized biomedical engineering curriculum would limit the scope of biomedical engineering to the detriment of what we now consider to be a very lively and responsive program. Third, we have yet to receive from employers either a clear indication of what they expect a biomedical engineer to be or a strong demand for biomedical engineers however vaguely defined. Principally, what we have perceived is a small but adequate market for able engineers who are adaptable and biomedically oriented and who can function effectively in a clinical environment, in an indus-
130
trial setting, or along with their colleagues trained in allied life sciences. The motivations have led to a practice that requires that the bicmedical aspects of the training come in addition to or in concert with rather than instead of the engineering training required of all graduate engineering students. Our graduate course requirements are typical in many respects, except that engineering courses are selected for their relevance, and often additional time is needed to take special biomedical and life science subjects. Our graduate thesis and dissertation requirements are also typical in that the student must meet the same technical standards set for all engineering students, but are atypical in that they are required to address in their research a biomedical problem. Over the years, the paucity of fixed departmental requirements, the diversity of our students, and our endeavors to match program to student have been such that a typical program cannot be given. However, when considering the electrical engineering graduate students who have elected to participate in our biomedical engineering program, it does seem that (1) electrical engineering electives have been concentrated heavily in the area of communication theory and digital computers; (2) mathematics electives have been concentrated in the areas of operations research and probability; and (3) life science electives have been concentrated in the physiology and neurophysiology areas. Due to a combination of historical accident, faculty interest, and government funding, our biomedical engineering program has produced students who fall into three loosely defined categories:
IEEE TRANSACTIONS ON BIOMEDICAL
ENGINEERING, MARCH i975
part of our program and the subject of this report was initiated in 1969 with the first large group of students entering in the fall of 1971. Graduates are educated to have engineering skills useful in health care delivery facilities. Many of these students are strong in the area of digital computer applications or electronics but have their training augmented by considerable practical experience. Two typical theses illustrative of the scope of the program are "Computer-Assisted Medical Questionnaire Design" and "A Computer Controlled Image Processing System for Automating the Kirby-Bauer Disc Sensitivity Test." Our biomedical engineering program has produced 54 graduates from the Electrical Engineering Department alone.' Approximately 55% of the electrical engineering graduate students enrolled in the fall of 1974 will participate in the interdepartmental program in one form or another. Table I shows data on the distribution of our current students relative to the above categories. It can be seen that the number of enrolled HCT candidates exceeds that of the BAC and EB groups combined even though our HCT program is more rigidly structured, more narrowly defined, and has a larger credit hour requirement (45 instead of 30) than the other two. Table II shows data on the distribution of our graduates relative to the nature of their employment or career activities. We can see from the table that field switching is not significant. But this observation must be tempered by two facts not brought out by Table II. First, roughly half of the graduates representing the BAC-BAC square are employed by Washington University in some clinically related capacity; this does not appear to be a "holding pattern" because their positions are relatively permanent. We believe that it does suggest that as the Medical Center computer activities grow, they continue to require additional biomedical computer experts. Second, the majority of graduates in the EB-EB square are at present continuing their education here or elsewhere and few have yet found stable employment in engineering biophysics. The HCT-HCT square in Table II is large in spite of the fact that that program has only been in its training phase for three years. Since the rate of graduation of HCT trained engineers is now considerably greater than that of the other twvo categories, and since the vast majority thus far are employed by health care delivery organizations or related industry, we feel that the HCT-HCT square will soon be very dominant. To the authors, all of whom appreciate keenly the pleasures of both the design of biomedical computing systems and the pursuit of biophysical research goals, the implication drawn from these data is unmistakable: the student demand for the Technology in Health Care Program is strong, as is that of employers for graduates of the program.
1) Biomedical Applications of Computers (BAC). This is the oldest part of our program and had its origin in the Washington University Computer Laboratories beginning in 1964. Students are well prepared in digital systems design and analysis, with special emphasis toward on-line applications of mini- and micro-computers. Their life science interests are strongly oriented toward medicine and human physiology. Typical thesis titles have been "Evaluation of Optimum and Suboptimum Processors for the Fetal Electrocardiogram" and "ARGUS, A Clinical Computer System for Monitoring Electrocardiographic Rhythms." 2) Engineering Biophysics (EB). Beginning in 1966 through the cooperation of the Departments of Electrical Engineering and Physiology and Biophysics and subsequently several other departments, these students have been trained to apply their engineering skills to the solution of problems more commonly attacked by biologists or physiologists. Their life science interests tend to lie in the electrophysiology-sensory physiology area. Thesis titles which illustrate the diversity of this program are "Measurement of Water Flux in Plant Stems" and "A 1 Approximately 75% of the biomedical engineering students have Nonlinear Model for Basilar Membrane Motion and been registered in the Department of Electrical Engineering, and since complete figures from that department are easily available to Related Phenomena of Single Cochlear Nerve Fibers." the authors, the data given below exclude students enrolled in other 3) Technology in Health Care (HCT). The newest departments.
cox
131
et al.: TRAINING PROGRAM IN HEALTH CARE
TABLE III
TABLE I
DISTRIBUTION OF PRESENT BIOMEDICAL ENGINEERING GRADUATE
STUDENTS
IN THE
DEPARTMENT
OF
BAC
EB
HCT
4
13
21
Fall Total-1974
TOTAL
Non-biomedical
EB*
HCT
Industry
Unknown
Total
BAC
9
2
0
2
4
17
EB
2
13
2
4
HCT
0
0
13
11
15
15
Trainin
Activity
Total
-- BAC
7
2
23
0
14
6
54
* For the purposes of this tabulation, a present activity in engineering biophysics is taken to be any life science related endeavor not fitting in the biomedical applications of computers or health care technology categories.
TECHNOLOGY IN HEALTH CARE The training program in Technology in Health Care at Washington University is an intensive 21-month program. The curriculum emphasizes engineering rigor and is directed toward fitting graduates for a career in applied engineering research in health care. Although the program is particularly designed for those who wish to put their training to practice immediately in hospitals, it also gives an excellent preparation to those who may elect to pursue either a doctorate in engineering or a career in industry. The objectives of the program are to provide its graduates with: 1) Graduate level competence in a traditional engineering field (electrical engineering, mechanical engineering, chemical engineering, or computer science); 2) Hospital experience in clinical engineering; the application of engineering to patient care and to hospital based biomedical research; 3) A fundamental knowledge of the technical aspects of electrical systems, hazards, and safety measures pertinent to hospitals and hospital instrumentation, as well as full cognizance of the national codes, standards, and laws that apply. 4) Fluency in the use of medical and physiological terminology; 5) Working experience with hospital information or
computer systems; 6) An introduction to hospital organization and administrative function; 7) Substantial experience working with and among hospital personnel including administrators, nurses, engineers, and medical staff. The academic requirements of the program are shown
in Table III.
Objetive
Obj ect ives Add ressed
1)
engineering subjects including special courses in Hospital Electrical Systems and Instrumentation, and Engineering Aspects of Health Care Delivery
2)
Mathematics, including a course in Operations Research
3)
Lectures in Preventive Medicine (School of Medicine) (Required of all freshmen medical students)
I
2, 4, 7
4)
Topics in Clinical Medicine (School of Medicine) (Required of all freshmen
2
2, 4, 7
38
TABLE II GRADUATE TRAINING VERSUS PRESENT ACTIVITY OF BIOMEDICAL ENGINEERING GRADUATES FROM THE DEPARTMENT OF ELECTRICAL ENGINEERING (M.S. AND D.SC. GRADUATES) Present
__auat
Graduate Credit Hours
ELECTRICAL ENGINEERING
Graduate
17 - 23
3
-
6
1, 3, 5
1, 5
medical students)
5)
A general human or vertebrate physiology course
(senior-graduate level)
3 - 4
4
Hospital administration* (Division of Health Care Administration, School of
3
6, 7
Technology in Health Care Internship (School of Engineering, School of Medicine, and selected area hospitals)
6
2, 3, 4, 6, 7
8)
Clinical Engineering Practicums 1,, II Ill
none
2, 4, 7
9)
Master's Degree Thesis
6
1, 2, 7
6)
Medicine) 7)
* Students select at least one course from the Health Care Administration Program. Relevant examples are: Health Facility Planning; Hospital Management; Seminar in Health Care Delivery; and Comprehensive Health Planning.
HOSPITAL EXPERIENCE The last three items in the list of academic requirements are not traditional classroom experience, but rather emphasize the practical side of health care technology. Most important of these experiences is the internship. During the summer between the first and second year of the program, students spend twelve weeks in hospitals and related health care facilities gaining familiarity with daily operations and the role of technology. The internship program is divided into two six-week segments, the first a highly organized sequence of visits to many facilities and the second an in-depth study of problems of a particular health care setting. During the past summer, fourteen hospitals were included in the schedule ranging from an older city hospital to a new and prosperous suburban hospital and from a research oriented medical center to a service oriented community hospital. A neighborhood clinic and two health-related companies were also included. Students generally traveled in pairs, and schedules emphasized several central topics each week. Meetings between all students and the faculty reviewed the facilities seen during the week, comparing and contrasting the variety of approaches to a central topic. The second half of the internship program contrasts with the survey nature of the first half. Each student with faculty advice selects a particular setting from among those visited earlier in the summer and engages in a detailed study of its opportunities for the application of technology. The Clinical Engineering Practicums I, II, III, noncredit subjects included in the academic requirements, provide several additional special opportunities for students
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to gain practical experience. Practicum I is taken in the first semester of the program and seeks to develop skills in the use and troubleshooting of electronic equipment, in the approach to systematic analysis and calibration, as well as in acquisition of the knowledge of contemporary fabrication techniques. The primary goal is to bolster those areas that may be applicable to training duties that may be required of graduates, e.g., training of technicians. Practicum II, taken in the second semester, concentrates on the hospital physical plant. Thus far, this has been carried out through the cooperation of the Barnes Hospital Maintenance and Engineering staff. Attention is given to preventive maintenance, electrical surveys, instrumentation renovation procedures and design, and hospital specification and documentation. The goal is to prepare for effective liaison with maintenance and outside architects and contractors while simultaneously increasing inhospital exposure during training. Practicum III will be first offered in fall 1974, and is directed toward clinical experience in special facilities such as the EEG clinic, the heart station, the catheterization laboratory, the X-ray department, and the rehabilitation clinic. Students are expected to gain direct experience with the present manner of operation of clinical facilities. The final component of the academic requirements, the thesis, also provides practical experience, but in depth in a specialized area of the application of technology to health care. Thesis topics are chosen to allow the student to use his engineering tools on a real clinical problem. The theses have been strong in engineering content, as would be a regular Master's Degree thesis at Washington University. Thesis topics and work have been particularly impressive to prospective employers.
PLACEMENT EXPERIENCE
have, in addition, placed two of our EB students (M.S. level) in similar hospital positions. The placement of students required unusual effort both on the part of the faculty and on the part of the individual students. For two consecutive years a brief brochure describing the program and its objectives, a cover letter soliciting inquiries, and a stamped return postcard were
mailed to the chief administrators of hospitals throughout the United States. The first year mailing was limited to those hospitals with more than 200 beds; the second included all hospitals (about 7,000) in the United States. Approximately 80-100 inquiries resulted from these mailings each year. Upon receipt of an inquiry3, student resumes and mnore details of the program were mailed, along with answers to any special questions posed by the inquirers. In addition to inquiries by mail, many telephone inquiries (more than 25) were also received. These contacts, however, were perhaps responsible for placement of less than half of the graduates. Their personal contacts with hospitals were most effective, and word-of-mouth was next most effective. Typical questions from interested hospitals included: What is the starting salary range? (Incidentally, in 1973 it was $13,000 to $14,70Q and in 1974 $13,500-$14,850.) Can students monitor service contracts? Are graduates interested in plant engineering responsibilities? Are students knowledgeable in codes, standards, and OSHA requirements? How soon will the average medium sized hospital be forced to hire clinical engineers? In add-ition, some indicated that they were only interested in a particular kind of engineer, e.g., a mechanical engineer. The majority of returns resulting from our mailings, however, did not have any special questions. Students have elected to pursue employment leads selectively or to initiate their own direct inquiries to hospitals as the result of several factors: geographical location, size of the hospital, prospective career development, and the nature of the hospital's requirements. Several apparently genuine inquiries, i.e., those with active job openings, were not pursued by any of the prospective graduates because either the hospital was interested in a plant engineer or was not located in a geographical region of interest to the students. Although several of the students had multiple job offers, the placement required attention and was not without some anxiety. On the other hand, we estimate conservatively that we could have placed, in the past year and one half, about eight to ten more engineers than were available. Timing was a major problem: Hospitals appear to decide to hire at all times of the year, but are unwilling or unable or unaccustomed to waiting for the academic cycle. We are, however, able to report that several places were quite disappointed when they failed to attract a graduate. In any event, positions appear to be more plentiful with time, and the outlook for well trained engineers appears to be good.
The design and development of our HCT program was initiated late in 1969; and after about a year and one half of work-deliberating, designing courses and curricula, developing hospital contacts-we started a class of nine students (1971). Subsequently, we have started three additional classes: nine students in 1972, ten students in 1973 and thirteen in 1974. Out of the 41 students who have started (as of June 1974), four have terminated, fourteen have graduated, two are finishing their theses, one is a doctoral student, seven are in their second half of the program, and thirteen are in the first half. Of the fourteen graduates, eleven are employed in health care technology positions, two are employed by industry and utilize their biomedical training, and one is in non-biomedical work. Of the eleven, four graduates were hired by the Veterans Administration, two are in the army, and seven were hired by private institutions or hospital groups. Those in private organizations acquired positions at an administrative level reporting directly to the hospital or group. director or assistant director. None have been subsumed under the maintenance or plant engineering EMPLOYMENT EXPERIENCE groups. To date, in most cases the health care technology Reaction from employers of our graduates has been engineer has had, upon being hired, great flexibility and We in and of his role position. the scope defining freedom positive. They have been willing to relay their experiences
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to other hospital administrators who are interested in exploring the possibility of a biomedical engineering staff member. They also have written letters of support for our program to federal administrators charged with policy decisions with regard to extension of the training grant program. The response from our graduates has been positive; all but one appear to be satisfied with their positions, responsibilities, and challenges. In the lone instance, the employment position lacks financial support and perhaps local interest, and is burdened by bureaucratic difficulties. A two-day meeting, eight months after the graduation of our first class, was attended by seven of the eight graduates, by all students in the program, and by all of the associated faculty. That meeting provided further insight into the needs of the hospital community, as well as an evaluation and critique of the positive and negative aspects of our program. Of special interest, we believe, is the great value that the graduates unanimously placed on the internship program. We are scheduling a second two-day symposium for all graduates (now including two classes) and all oncampus students so that we may continue to evaluate and modify our program.
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tors: the quality of the students, the quality of their training, and the quality of their performances. All, of course, are related. Students graduating from "clinical engineering" programs must be able to compete with their contemporaries trained in traditional engineering fields. If they cannot, we feel that their ultimate impact and the number of opportunities in the health care scene will be limited and disappointing. Any compromise of the technical competence of the student is an injustice to the student, to his employer, and to the profession. To this end we believe that rigorous programs designed to train engineers rather than merely designed to attract students are required. Depth and rigor in engineering must go hand in hand with practical clinical experience to insure the growth and vigor of this new profession that links medicine and engineering.
ACKNOWLEDGMENT We wish to acknowledge the continuing support and attention of the Health Resources Administration (formerly the Health Services and Mental Health Administration). We further wish to acknowledge that the success of this program would not be possible without the superb collaboration and genuine interest of members of the CONCLUSION Washington University School of Medicine and the Barnes We feel that the future for engineers in health care is Hospital of St. Louis. The program has been further relatively bright. However, the extent to which they are enhanced by association with the staff of many other accepted and sought after depends upon several key fac- hospitals in the St. Louis metropolitan area.
