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SHOULD THE MEDICAL CURRICULUM BE MODIFIED TO INFLUENCE CAREER CHOICE AND IF SO, HOW? STEVEN C. BEERING, M.D. Dean, Indiana University School of Medicine Indianapolis, Ind.
S HOULD the medical curriculum be modified to influence career choice? This question implies that the M.D. curriculum can influence career choice and also that the present state of affairs is stationary or at least stable. There are now 114 medical schools in the United States; 11 of them accept high school graduates, 17 have three-year-degree programs, 91 offer programs leading to simultaneous Masters or Ph.D. and M.D. degrees. However, all curricula share certain common characteristics: a basic science component, usually consisting of clinical core and clerkships, and an elective or selective component. Further, all schools share the characteristic of being located midway in the educational process that produces a practicing physician. Dr. Morton Bogdonoff stated in the Archives of Internal Medicine1 last year that it usually requires three schools to produce a practitioner: a college, a medical school, and a hospital. I think it also takes a fourth: the school of hard knocks, better known as medical practice. Dr. William E. Cadbury, speaking at the Symposium on the Education of Tomorrow's Physicians at the New York Academy of Medicine in October 1972,2 emphasized that the broadly educated college student was more likely to serve society well. He went on to describe the dilemma of premedical advisors who year after year saw their science majors succeed in getting into medical school and staying there. The premedical courses required by our medical schools today are so modest as to hardly be worthy of a future physician scientist (or any other educated person for that matter); yet, our colleges persist in pushing young medical hopefuls into *Presented as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
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the all-too-familiar molds. Our admissions committee at Indiana University School of Medicine this past year selected more than half of the 305 entering students from applicants who did not major in chemistry or zoology, but it was not easy. 1 We also selected about one third of our class from students with rural backgrounds and about one third from college juniors. Ten percent of our incoming class chose a combined degree option. Our program has been in operation for 17 years and has graduated 450 individuals, the majority of whom are in clinical practice. One half of our entering group chose to pursue their first year of medical education at one of our seven centers for medical education away from the main campus. I emphasize that they volunteered to do so. Dr. Ivan Bennett, in his address to the Academy at the same symposium,3 outlined curricular trends then in evidence. I shall review and comment on some of them. 1) The integration of college and medical school. There are still a few sporadic experiments, but this is not an active trend today. 2) The increasing coordination of basic and clinical science. This trend is actively pursued as an elective in most schools, but is judged generally to have fallen short of the mark. 3) Early patient contact. Still a common trend. 4) A shortening of the curriculum. This was the vogue a little while ago; it generally is no longer in evidence. 5) Teaching machines and computers. This is pedagogically interesting, but not a mushrooming development. It is very costly and it is, in the terminology of today's medical student, dehumanizing. 6) The emphasis on ambulatory instruction. This remains a strong trend and major challenge. 7) The increasing use of electives in the curriculum. This is now so universal as to no longer be a trend. Electives are part of the curriculum of all schools in both the United States and Canada. One school, Stanford University School of Medicine, has a totally elective curriculum. 8) Another major trend in evidence today is community orientation and primary-care education. How socially conscious are our schools? A recent survey by the Association of American Medical Colleges netted responses from 65 of our 114 schools. These schools are conducting one or more programs designed to effect better distribution of physicians by specialty and geography, increase primary-care education, integrate and coordinate residency pro-
Bull. N. Y. Acad. Med.
SHOULD THE CURRICULUM INFLUENCE CAREER CHOICE?
1093
grams, provide more equitable programs for foreign medical graduates (FMGs), increase their community orientation, develop new kinds of health manpower, and provide a variety of programs in health-care research, among others. We can conclude that the schools have been quite responsible to local and national needs and to private and public concerns. The curricula have been anything but static. Clearly, much is being done. What else might be needed? First, we need a realistic reassessment of the aims and purposes of the medical school itself. We must not be lulled into complacency by our successes, otherwise, the fate of our institutions may be similar to that of the railroads. Theodore Levitt, writing in the Harvard Business Review recently,4 titled this problem "marketing myopia." He describes this as characterizing industries which focus on a single product to their detriment. For example, the railroads failed to appreciate the opportunity of expanding into other modes of transportation; the film-makers first ignored and then fought television instead of developing this new medium of entertainment; and the oil companies only recently have started to develop alternate energy resources. While the primary product of the medical school has been the undifferentiated physician, we must recognize that today we are not just educating physicians. The medical school also creates a host of other products: patient care-especially primary care; research-particularly in health care; other kinds of health professionals-physician assistants, nurse-practitioners, and so on; and continuing education, of course, a special challenge, the education of our consumers (physicians), our patients, and potential patients. Second, we urgently need a strategic plan which will achieve diversification on a broad base in order to meet today's needs and tomorrow's demands. Too often we react rather than act. We are hampered in this planning effort by our institutional orientation toward crises and by our negative marketing history-we are the only American industry trying to promote a product by emphasizing repairs. We must change from our negative and narrow view to the positive recognition that we are in the total health business, not simply in the undifferentiated physician-production business. John G. Freyman, now president of the National Fund for Medical Education, wrote in his provocative analysis of The American Health Care System; Its Genesis and Trajectory in 1964:5 "The primary concern of
Vol. 52, No. 9, November 1976
1094
1094
S. C. BEERING S.
C.
BEERINO~-
clinical medicine is no longer the patient in imminent danger of death. It is the prevention of disease and injury." In addition, Dr. Leon White pointed out in the October 1975 issue of the New England Journal of Medicine6 that the health-care crisis today is a crisis of life-style-drugs, alcohol, tobacco, automobiles, speed, over-eating, inadequate exercise, and so on. Which of the federal initiatives now under consideration address these issues? Will mandates, quotas, and coercive measures produce the desired results? I think not. In the state of Indiana we have been using positive reinforcement, a system of rewards and incentives, for a decade now with success. Indiana has 51/2 million people and only one medical school. In 1965 we were admitting 225 medical students annually and routinely lost two thirds of them to other states upon graduation. We had residencies in only two cities: Indianapolis and South Bend. Continuing education consisted of 12 venerated annfal courses given at the medical school with titles like "Electrocardiography for the General Practitioner," and "What's New in GI." There was a shortage of physicians of all sorts. After a good deal of study by councils, commissions, committees, boards, consultants, the legislature, the medical school, and the universities, we evolved a plan to deal with these problems strategically and in a future-oriented manner. First, we wanted to improve the professional environment. We decided this could be done best by paying attention to the community hospital and continuing education. Second, we wanted to increase the residency opportunities for our graduates, because numerically there were not enough places in these two cities for even half of our graduates. Third, if successful, we would attempt to increase the size of the entering medical class by utilizing a decentralized approach. This entailed harnessing the facilities and faculties of six major universities and a large variety of hospitals in the nine cities which serve as the trade areas in our state. Our school did not then and does not today need to affiliate with other hospitals for lack of beds; there are 2,300 beds in the Indiana University Medical Center. In addition, for many years we have had 4,000 affiliated beds within a 15-mile radius of the medical center. So the decision to decentralize statewide was a deliberate one and not a response to the pressures of 1975. Initially, we recruited the collaboration of six universities, including the private ones like the University of Notre Dame and the University of Evansville and public ones like Indiana State University, Ball State University, and Purdue University and about two dozen Bull. N. Y. Acad. Med.
SHOULD THE CURRICULUM INFLUENCE CAREER CHOICE?
1095
additional hospitals throughout the state. The state of Indiana gave this plan unanimous support in the legislature and an initial allocation of $2.5 million to be spent in part at the medical school but in the main at the community hospitals. How did this all work out? The special state appropriation provided for the establishment and maintenance of a sophisticated biomedical communication network which today involves 198 community libraries and six universities and their regional campuses. We have in place a functioning two-way telecommunication network employing computers, telephones, and television. Our medical color television is on the air eight hours a day, five days a week; it reaches 27 hospitals and 10 campuses live, and an additional 63 hospitals and some 50 individual physicians receive the programs on videotape. Individual physicians may call the school's departments or medical library by telephone at the expense of the statewide system. More than two thirds of our library transactions now are generated from outside the medical center. Courses. Sixty percent of all practicing physicians in the state attended one or more formal postgraduate courses at the medical center and community hospitals this past year. Participating community hospitals receive grant support for residents on a capitation basis, $2,350 for each nonprimary care resident and $8,000 each for those in family medicine. Hospitals also receive incentive grants-in-aid for the improvement of programs. For example, recently we gave out a series of small grants ($25,000 to $50,000) to hospitals that wished to start residencies in family medicine. Visiting professorships. We also fund a series of visiting professorships; last year this program involved 350 individual faculty members who traveled to 27 different hospitals around the state. This effort is administered by the medical school and is financed by the hospitals through their individual grants-in-aid. Graduate education. When this program was initiated in 1967 there were 420 interns and residents pursuing their education in the state, with the majority in programs on the medical center campus. In 1975 there were 740 residents in eight cities throughout the state. Since the inception of the program, there has been an increase of 320 persons in training, a 76% increase over 1967. Of this number, 379 residents, or 52%, are training in primary care. I also might note that about 95% of all available positions now are filled with American graduates. Our total FMG component in all residencies throughout the state is only about 5%. We turned away about Vol. 52, No. 9, November 1976
1096
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S. C. BEERING
S.
C.
BEERING~~~~~~~~~~~~~~~~~~~~~~~~~
200 applicants for programs in internal medicine and about that number for family-practice programs. There are now 27 hospitals linked with the medical school in a coordinated program of statewide graduate medical education. Undergraduate education. In this area the revised medical school curriculum has allowed for a totally elective senior year and the creation of some 500 elective courses at 74 community hospitals. For each of the past six years, well over 50% of our senior medical students' unit time has been spent in rotations away from the Indianapolis Medical Center campus. Attraction of physicians. For each of the past six years the number of newly licensed physicians in Indiana has risen at an annual rate of 3%, while the state's population has increased by only about 1%. During the years before 1965 the state routinely retained 40% of our graduates. For the last six years we have been averaging a 55% retention of our own graduates, and in the last two years it was 60%. This takes on added significance in view of the larger graduating classes. Following the successful pilot programs at Purdue and Notre Dame Universities in 1968, and using the medical sciences combined degree program at our Bloomington campus as a model, we established seven new centers for medical education; these were to operate in conjunction with the six major institutions of higher education and some 22 large community hospitals in the state. These centers have made possible a 30% increase in the enrollment of freshmen medical students and, consequently, 375 additional students who otherwise would not have been accommodated in medical school are now in training. Geographic distribution. The number of cities in Indiana with programs of graduate education has now risen to nine. In the last six years three new residencies in internal medicine and eight new residencies in family medicine were established. The total number of hospitals participating in one or more of these program components has increased to 90. The number of family-practice preceptors has increased to 40. The medical school faculty now numbers 1,300 members, including 20% of the state's practicing physicians; and the full-time faculty of the school has risen from about 300 individuals to 505, with another 120 teaching part-time. Of the entering class of 305, nearly half of the class, 145, are now taking their first year at one of the seven branches in the system. They return to Indianapolis in the second year, with the exception of the Bloomington program, which is a two-year affair. All students have their
Bull. N. Y. Acad. Med.
SHOULD THE CURRICULUM INFLUENCE CAREER CHOICE?
1097
third-year clerkships in Indianapolis; the fourth year is totally elective. Further, as part of the center system, we are conducting a two-year program for physician assistants at our Fort Wayne Center and a program for family-nurse-practitioners and child-nurse associates on the Indianapolis campus. When a people legislates health care as an individual right it incurs health-care education as a societal responsibility. This responsibility can only be discharged effectively by a partnership approach, not an alternative approach. Indeed, there is strength in diversity and collaborative effort, in a joint venture by public and private sectors. Those who live, work, and teach in an environment of vertical reality, not just the horizontal complexity of the referral hospital, will welcome the challenge of change. I urge you to take the initiative. Reach out and become the catalyst for this continuum of medical education. The prize is success; better care for patients, support by legislators, and stimulating new opportunities for faculties. REFERENCES
1.Bogdonoff, M.: A Note On The Administration of Graduate Education. Arch. Intern. Med. 135:620-22, 1975. 2.Cadbury, W. E.: Education of the premedical student in the humanities and the biological and physical sciences. Bull. N.Y. Acad. Med. 49:264, 1973. 3.Bennett, I. L., Jr.: Trends and objectives in medical education. Bull. N.Y. Acad. Med. 49:337-48, 1973.
Vol. 52, No. 9, November 1976
4. Levitt, T.: Marketing myopia. Harvard Bus. Rev. 53:23, 1975. 5. Freyman, J. G.: The American Health Care System: Its Genesis and Trajectory. Baltimore, Williams and Wilkins, 1974. 6.White, L. S.: The health care system. N. Engl. J. Med. 293:773-4, 1975.
SHOULD THE MEDICAL CURRICULUM BE MODIFIED TO INFLUENCE CAREER CHOICE AND IF SO, HOW? STEVEN C. BEERING, M.D. Dean, Indiana University School of Medicine Indianapolis, Ind.
S HOULD the medical curriculum be modified to influence career choice? This question implies that the M.D. curriculum can influence career choice and also that the present state of affairs is stationary or at least stable. There are now 114 medical schools in the United States; 11 of them accept high school graduates, 17 have three-year-degree programs, 91 offer programs leading to simultaneous Masters or Ph.D. and M.D. degrees. However, all curricula share certain common characteristics: a basic science component, usually consisting of clinical core and clerkships, and an elective or selective component. Further, all schools share the characteristic of being located midway in the educational process that produces a practicing physician. Dr. Morton Bogdonoff stated in the Archives of Internal Medicine1 last year that it usually requires three schools to produce a practitioner: a college, a medical school, and a hospital. I think it also takes a fourth: the school of hard knocks, better known as medical practice. Dr. William E. Cadbury, speaking at the Symposium on the Education of Tomorrow's Physicians at the New York Academy of Medicine in October 1972,2 emphasized that the broadly educated college student was more likely to serve society well. He went on to describe the dilemma of premedical advisors who year after year saw their science majors succeed in getting into medical school and staying there. The premedical courses required by our medical schools today are so modest as to hardly be worthy of a future physician scientist (or any other educated person for that matter); yet, our colleges persist in pushing young medical hopefuls into *Presented as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
1092
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S. C. BEERING
the all-too-familiar molds. Our admissions committee at Indiana University School of Medicine this past year selected more than half of the 305 entering students from applicants who did not major in chemistry or zoology, but it was not easy. 1 We also selected about one third of our class from students with rural backgrounds and about one third from college juniors. Ten percent of our incoming class chose a combined degree option. Our program has been in operation for 17 years and has graduated 450 individuals, the majority of whom are in clinical practice. One half of our entering group chose to pursue their first year of medical education at one of our seven centers for medical education away from the main campus. I emphasize that they volunteered to do so. Dr. Ivan Bennett, in his address to the Academy at the same symposium,3 outlined curricular trends then in evidence. I shall review and comment on some of them. 1) The integration of college and medical school. There are still a few sporadic experiments, but this is not an active trend today. 2) The increasing coordination of basic and clinical science. This trend is actively pursued as an elective in most schools, but is judged generally to have fallen short of the mark. 3) Early patient contact. Still a common trend. 4) A shortening of the curriculum. This was the vogue a little while ago; it generally is no longer in evidence. 5) Teaching machines and computers. This is pedagogically interesting, but not a mushrooming development. It is very costly and it is, in the terminology of today's medical student, dehumanizing. 6) The emphasis on ambulatory instruction. This remains a strong trend and major challenge. 7) The increasing use of electives in the curriculum. This is now so universal as to no longer be a trend. Electives are part of the curriculum of all schools in both the United States and Canada. One school, Stanford University School of Medicine, has a totally elective curriculum. 8) Another major trend in evidence today is community orientation and primary-care education. How socially conscious are our schools? A recent survey by the Association of American Medical Colleges netted responses from 65 of our 114 schools. These schools are conducting one or more programs designed to effect better distribution of physicians by specialty and geography, increase primary-care education, integrate and coordinate residency pro-
Bull. N. Y. Acad. Med.
SHOULD THE CURRICULUM INFLUENCE CAREER CHOICE?
1093
grams, provide more equitable programs for foreign medical graduates (FMGs), increase their community orientation, develop new kinds of health manpower, and provide a variety of programs in health-care research, among others. We can conclude that the schools have been quite responsible to local and national needs and to private and public concerns. The curricula have been anything but static. Clearly, much is being done. What else might be needed? First, we need a realistic reassessment of the aims and purposes of the medical school itself. We must not be lulled into complacency by our successes, otherwise, the fate of our institutions may be similar to that of the railroads. Theodore Levitt, writing in the Harvard Business Review recently,4 titled this problem "marketing myopia." He describes this as characterizing industries which focus on a single product to their detriment. For example, the railroads failed to appreciate the opportunity of expanding into other modes of transportation; the film-makers first ignored and then fought television instead of developing this new medium of entertainment; and the oil companies only recently have started to develop alternate energy resources. While the primary product of the medical school has been the undifferentiated physician, we must recognize that today we are not just educating physicians. The medical school also creates a host of other products: patient care-especially primary care; research-particularly in health care; other kinds of health professionals-physician assistants, nurse-practitioners, and so on; and continuing education, of course, a special challenge, the education of our consumers (physicians), our patients, and potential patients. Second, we urgently need a strategic plan which will achieve diversification on a broad base in order to meet today's needs and tomorrow's demands. Too often we react rather than act. We are hampered in this planning effort by our institutional orientation toward crises and by our negative marketing history-we are the only American industry trying to promote a product by emphasizing repairs. We must change from our negative and narrow view to the positive recognition that we are in the total health business, not simply in the undifferentiated physician-production business. John G. Freyman, now president of the National Fund for Medical Education, wrote in his provocative analysis of The American Health Care System; Its Genesis and Trajectory in 1964:5 "The primary concern of
Vol. 52, No. 9, November 1976
1094
1094
S. C. BEERING S.
C.
BEERINO~-
clinical medicine is no longer the patient in imminent danger of death. It is the prevention of disease and injury." In addition, Dr. Leon White pointed out in the October 1975 issue of the New England Journal of Medicine6 that the health-care crisis today is a crisis of life-style-drugs, alcohol, tobacco, automobiles, speed, over-eating, inadequate exercise, and so on. Which of the federal initiatives now under consideration address these issues? Will mandates, quotas, and coercive measures produce the desired results? I think not. In the state of Indiana we have been using positive reinforcement, a system of rewards and incentives, for a decade now with success. Indiana has 51/2 million people and only one medical school. In 1965 we were admitting 225 medical students annually and routinely lost two thirds of them to other states upon graduation. We had residencies in only two cities: Indianapolis and South Bend. Continuing education consisted of 12 venerated annfal courses given at the medical school with titles like "Electrocardiography for the General Practitioner," and "What's New in GI." There was a shortage of physicians of all sorts. After a good deal of study by councils, commissions, committees, boards, consultants, the legislature, the medical school, and the universities, we evolved a plan to deal with these problems strategically and in a future-oriented manner. First, we wanted to improve the professional environment. We decided this could be done best by paying attention to the community hospital and continuing education. Second, we wanted to increase the residency opportunities for our graduates, because numerically there were not enough places in these two cities for even half of our graduates. Third, if successful, we would attempt to increase the size of the entering medical class by utilizing a decentralized approach. This entailed harnessing the facilities and faculties of six major universities and a large variety of hospitals in the nine cities which serve as the trade areas in our state. Our school did not then and does not today need to affiliate with other hospitals for lack of beds; there are 2,300 beds in the Indiana University Medical Center. In addition, for many years we have had 4,000 affiliated beds within a 15-mile radius of the medical center. So the decision to decentralize statewide was a deliberate one and not a response to the pressures of 1975. Initially, we recruited the collaboration of six universities, including the private ones like the University of Notre Dame and the University of Evansville and public ones like Indiana State University, Ball State University, and Purdue University and about two dozen Bull. N. Y. Acad. Med.
SHOULD THE CURRICULUM INFLUENCE CAREER CHOICE?
1095
additional hospitals throughout the state. The state of Indiana gave this plan unanimous support in the legislature and an initial allocation of $2.5 million to be spent in part at the medical school but in the main at the community hospitals. How did this all work out? The special state appropriation provided for the establishment and maintenance of a sophisticated biomedical communication network which today involves 198 community libraries and six universities and their regional campuses. We have in place a functioning two-way telecommunication network employing computers, telephones, and television. Our medical color television is on the air eight hours a day, five days a week; it reaches 27 hospitals and 10 campuses live, and an additional 63 hospitals and some 50 individual physicians receive the programs on videotape. Individual physicians may call the school's departments or medical library by telephone at the expense of the statewide system. More than two thirds of our library transactions now are generated from outside the medical center. Courses. Sixty percent of all practicing physicians in the state attended one or more formal postgraduate courses at the medical center and community hospitals this past year. Participating community hospitals receive grant support for residents on a capitation basis, $2,350 for each nonprimary care resident and $8,000 each for those in family medicine. Hospitals also receive incentive grants-in-aid for the improvement of programs. For example, recently we gave out a series of small grants ($25,000 to $50,000) to hospitals that wished to start residencies in family medicine. Visiting professorships. We also fund a series of visiting professorships; last year this program involved 350 individual faculty members who traveled to 27 different hospitals around the state. This effort is administered by the medical school and is financed by the hospitals through their individual grants-in-aid. Graduate education. When this program was initiated in 1967 there were 420 interns and residents pursuing their education in the state, with the majority in programs on the medical center campus. In 1975 there were 740 residents in eight cities throughout the state. Since the inception of the program, there has been an increase of 320 persons in training, a 76% increase over 1967. Of this number, 379 residents, or 52%, are training in primary care. I also might note that about 95% of all available positions now are filled with American graduates. Our total FMG component in all residencies throughout the state is only about 5%. We turned away about Vol. 52, No. 9, November 1976
1096
1096
S. C. BEERING
S.
C.
BEERING~~~~~~~~~~~~~~~~~~~~~~~~~
200 applicants for programs in internal medicine and about that number for family-practice programs. There are now 27 hospitals linked with the medical school in a coordinated program of statewide graduate medical education. Undergraduate education. In this area the revised medical school curriculum has allowed for a totally elective senior year and the creation of some 500 elective courses at 74 community hospitals. For each of the past six years, well over 50% of our senior medical students' unit time has been spent in rotations away from the Indianapolis Medical Center campus. Attraction of physicians. For each of the past six years the number of newly licensed physicians in Indiana has risen at an annual rate of 3%, while the state's population has increased by only about 1%. During the years before 1965 the state routinely retained 40% of our graduates. For the last six years we have been averaging a 55% retention of our own graduates, and in the last two years it was 60%. This takes on added significance in view of the larger graduating classes. Following the successful pilot programs at Purdue and Notre Dame Universities in 1968, and using the medical sciences combined degree program at our Bloomington campus as a model, we established seven new centers for medical education; these were to operate in conjunction with the six major institutions of higher education and some 22 large community hospitals in the state. These centers have made possible a 30% increase in the enrollment of freshmen medical students and, consequently, 375 additional students who otherwise would not have been accommodated in medical school are now in training. Geographic distribution. The number of cities in Indiana with programs of graduate education has now risen to nine. In the last six years three new residencies in internal medicine and eight new residencies in family medicine were established. The total number of hospitals participating in one or more of these program components has increased to 90. The number of family-practice preceptors has increased to 40. The medical school faculty now numbers 1,300 members, including 20% of the state's practicing physicians; and the full-time faculty of the school has risen from about 300 individuals to 505, with another 120 teaching part-time. Of the entering class of 305, nearly half of the class, 145, are now taking their first year at one of the seven branches in the system. They return to Indianapolis in the second year, with the exception of the Bloomington program, which is a two-year affair. All students have their
Bull. N. Y. Acad. Med.
SHOULD THE CURRICULUM INFLUENCE CAREER CHOICE?
1097
third-year clerkships in Indianapolis; the fourth year is totally elective. Further, as part of the center system, we are conducting a two-year program for physician assistants at our Fort Wayne Center and a program for family-nurse-practitioners and child-nurse associates on the Indianapolis campus. When a people legislates health care as an individual right it incurs health-care education as a societal responsibility. This responsibility can only be discharged effectively by a partnership approach, not an alternative approach. Indeed, there is strength in diversity and collaborative effort, in a joint venture by public and private sectors. Those who live, work, and teach in an environment of vertical reality, not just the horizontal complexity of the referral hospital, will welcome the challenge of change. I urge you to take the initiative. Reach out and become the catalyst for this continuum of medical education. The prize is success; better care for patients, support by legislators, and stimulating new opportunities for faculties. REFERENCES
1.Bogdonoff, M.: A Note On The Administration of Graduate Education. Arch. Intern. Med. 135:620-22, 1975. 2.Cadbury, W. E.: Education of the premedical student in the humanities and the biological and physical sciences. Bull. N.Y. Acad. Med. 49:264, 1973. 3.Bennett, I. L., Jr.: Trends and objectives in medical education. Bull. N.Y. Acad. Med. 49:337-48, 1973.
Vol. 52, No. 9, November 1976
4. Levitt, T.: Marketing myopia. Harvard Bus. Rev. 53:23, 1975. 5. Freyman, J. G.: The American Health Care System: Its Genesis and Trajectory. Baltimore, Williams and Wilkins, 1974. 6.White, L. S.: The health care system. N. Engl. J. Med. 293:773-4, 1975.
