Refer to: Rosinski EF: The Central San Joaquin Valley Area Health Education Center (Medical Education). West J Med 128:355-359, Apr 1978
Medical Education
The Central San Joaquin Valley Health Education Center
Area
EDWIN F. ROSINSKI, EdD, San Francisco
With federal financial support, an area health education center was established in the central San Joaquin Valley of California. The center is a cooperative health sciences education and health care program organized by the University of California and some of the educational and health care institutions of the valley. The center's goals include providing and improving primary health care education, and improving the distribution of health personnel. These goals are achieved through the cooperative development of a number of independent and interdependent activities. An extensive evaluation of the Area Health Education Center has shown that it is a highly effective program.
THE CARNEGIE COMMISSION ON HIGHER EDUCATION in its Report on Higher Education and the Nation's Health proposed the development of area health education centers (AHEC) as a means of developing health manpower in geographic areas without a university medical center. In making the proposal, the Carnegie Commission defined the role of an AHEC: ... centers would be affiliated with the nearest university health science center, and would perform somewhat the same functions recommended for university health sciences centers except that the education of MD and DDS candidates would be restricted to a limited amount of clinical education on a rotational basis, and research programs would be largely restricted to the evaluation of local experiments in health care delivery systems.'
As proposed by the Commission, the AHEC'S would essentially be extensions or satellites of Dr. Rosinski is Professor of Medical Education and Director, Office of Medical Education, University of California, San Francisco, School of Medicine. Reprint requests to: Edwin F. Rosinski, EdD, Office of Medical Education, UC, San Francisco, 50 Kirkham St., San Francisco, CA 94143.
university health science centers. The AHEC'S would be visited regularly by university faculty who would give lectures and seminars, attend clinics, make ward rounds and the like. Educational programs would be developed by the participating institutions in collaboration with the university faculty. As the AHEC's developed, they in turn would provide assistance to other community institutions and health care facilities. The AHEC concept had almost instant approval from most quarters of health sciences education. The federal government endorsed the AHEC concept because past experience indicated that university health centers could not respond, by themselves, to such pressing issues as geographic and specialty maldistribution of health personnel. It was believed that a consortium of institutionssecondary schools, community colleges, state colleges, universities, community hospitals and clinics, governmental and private agencies, voluntary health agencies, health professions organizaTHE WESTERN JOURNAL OF MEDICINE
355
AREA HEALTH EDUCATION CENTER
ABBREVIATIONS USED IN TEXT AHEC=area health education center CSJV=central San Joaquin Valley UCLA= University of California, Los Angeles UCSF=University of California, San Francisco VMC= Valley Medical Center
tions and others-working together, each contributing a unique resource in the development of health personnel programs, was an approach that had merit and should be tested. Legislation to support AHEC'S was developed and the Comprehensive Health Manpower Training Act of 1971 (Public Law 92-157) enacted by Congress made them a reality. Section 774A of that law suggested that a number of goals be established for federally supported AHEC'S. They included, among others, the following: identifying the need for health personnel; providing educational programs for medical students, residents and allied health personnel; providing continuing education programs for health personnel; developing resources in order to attract health personnel to medically underserved areas; coordinating health personnel training programs, and developing new health careers. To encourage the development of AHEC's, the federal government invited university health sciences centers to submit proposals on how they might initiate such programs in their areas. The federal invitations were in the form of a Request for Proposal (RFP) for contracts that would be critically reviewed and would be competitive. Funds were limited, consequently the initial number of AHEC's also would be limited. The schools of medicine of the University of California, San Francisco (UCSF) and Los Angeles (UCLA), viewed the AHEC concept as one means by which they could extend their resources to a medically underserved area in California, while at the same time assisting the area in the development of its own health sciences education and health care resources. While many areas in California might qualify as being "medically underserved," it was agreed that the central San Joaquin Valley (CsJv) had the potential to continue the development of its health sciences education and health care programs when university participation in the development and operation of the AHEC came to an end. The CSJV was an excellent place in which to locate and initiate an AHEC. For many years the 356
APRIL 1978
*
128
*
4
community had a strong interest in beginning a medical education activity and superb leadership was provided by a number of outstanding persons in the community. The community leadership organized itself into the Central San Joaquin Valley Health Consortium and the consortium had as its primary goal fostering the development of health sciences education in the area. Furthermore, the community had developed the groundwork for a program such as the AHEC through its involvement in a number of activities related to the former Regional Medical Program, and from the efforts to establish a modified AHEC approach through funding by the Veterans Administration at the Fresno Veterans Administration Hospital. It was an appropriate time for a joint effort between the medical schools and the csJv Health Consortium to launch a program that would expand and develop the valley's health sciences and health care resources. The schools of medicine at UCSF and UCLA were fully aware that it would be presumptuous to initiate unilaterally an AHEC in a community almost 250 miles away. Since the schools had good relations with the health consortium it was relatively easy to get the concerned parties together to develop AHEC proposals. Finally, both UCLA and UCSF prepared proposals, but the government decided that the two proposals should be combined, and awarded the contract to UCSF. The deans of both medical schools then decided which campus would be responsible for what, and the Central San Joaquin Valley AHEC-one of 11 area health education centers approved and funded in the country-began operation. The San Francisco campus was designated the prime contractor, while UCLA contracted to carry out certain activities and fulfilled its contractual obligations. For a project as large as the CSJV-AHEC, the administrative staff is remarkably small. The Project Director is the Associate Dean, Extended Programs in Medical Education at UCSF, and he has a full-time assistant who handles the day-today operation and supervises the staff, almost all of whom are located in Fresno. In addition, the position of Associate Director, UCLA, has been maintained to provide leadership for the UCLA activities. The Project Director has an advisory committee consisting of members of the AHEC community, and faculty members from UCLA and
AREA HEALTH EDUCATION CENTER
UCSF. The advisory committee meets at regular intervals to discuss and consider policy and, once a year, to select its own chairperson. Staff meetings, consisting primarily of the directors of each of the component programs, are held at irregular intervals. The purpose of the staff meetings is to keep everyone involved in the project informed about activities in each component program. Once a year the program directors submit their plans and budgets for the coming year to the Project Director and these plans are discussed at a staff meeting. The Project Director submits a budget to the Department of Health, Education, and Welfare where it is critically reviewed by the contract officer of the local Department of Health, Education, and Welfare Regional Office. An unusual feature of the AHEC legislation was the requirement that every program be evaluated. With the federal government increasingly concerned with accountability, the legislation clearly stipulated that evaluation should be a major activity of each AHEC. Sensitive. to the need for an impartial evaluation, the Project Director requested a number of persons to submit proposals to evaluate the program. One was selected and periodic reports are made to the Project Director on the progress of the entire project as well as the progress of each component program. A final report upon conclusion of the initial funding of the project essentially answered the question "Was it a success?" The CSJV-AHEC began on October 1, 1972. The AHEC is a series of independent and interdependent individual programs all directed toward achieving one or more of the goals of the national AHEC program, which are the following: (1) To improve the specialty and geographic distribution, supply, quality, utilization, and efficiency of health personnel in the health delivery system. (2) To improve the regional development of educational responsibilities of health professions schools. (3) To effect change in the distribution of health personnel and the accessibility to quality health care in the AHEC area. The AHEC began with 13 programs and during year five, the last year of the initial funding of the project, there were 23 programs. During the course of the five years a number of programs were discontinued because they did not meet either the goals of the AHEC or the program objectives. Other programs were ended because they had met all of their objectives, while others were added which in the judgment of the
Project Director and his advisory committee and the government were considered compatible with the overall goals of the AHEC. A brief description of some of the component programs should illustrate how the AHEC works. One of the more specific objectives of the AHEC is to provide and to improve primary health care education in the valley. The family medicine residency program is affiliated with the Division of Community and Ambulatory Medicine of the School of Medicine, UCSF, and is one of several programs working toward achieving that objective. The family medicine residency program carried out the following activities in the valley: (1) developed an affiliation between the Valley Medical Center (vMc) and UCSF; (2) developed community medicine rotations in rural patient care facilities; (3) developed medical student elective clerkships at vMc; (4) used faculty from UCSF and other university health science centers as teaching consultants to the VMC, and (5) provided lectures and seminars at the VMC for medical students, residents and private practitioners. Another program directed toward improving primary health care education is the video tapes program. Video tapes on primary medical care topics are developed by UCSF and made available to practitioners in the valley. The family medicine residency program and the video tapes programs are independent activities, but in many ways are interdependent because they are both directed toward providing and improving primary health care education. As can be seen in the family medicine residency program, all of the UCSF efforts are directed toward assisting existing institutions in the valley by strengthening their capabilities to provide primary medical care. At the same time, it is appreciated that there are a number of resources in the valley that can be tapped for the education of medical students and residents-or in bureaucratic jargon, UCSF has sought to develop "linkages" between its campus and institutions in the valley. A brief review of some of the other component programs should further illustrate how the entire project is geared toward achieving the three previously cited major goals of the national AHEC program. A drug information program provides drug information to health professionals on all aspects of drugs, drug therapy and drug toxicity. The biomedical library resources program had as its goal the improvement of biomedical resources and THE WESTERN JOURNAL OF MEDICINE
357
AREA HEALTH EDUCATION CENTER
information services. A health administrators program set out to upgrade the capabilities of rural health administrators. The pediatric nurse associate program first assessed whether there was a need for personnel of this type, and after determining that there was, began to develop an appropriate training program. The number of dental hygienists was increased through the development of the dental hygiene program at Fresno City College, and a program for training dental laboratory technicians was inaugurated at Merced Community College. A number of programs contained continuing education activities; these included medicine, dentistry, nursing and the allied health professions. One program had a rather specific objective and that was to promote the continuous improvement of services in the intensive care of patients. Perhaps while this program might not be considered primary medical care, it was felt that it was in keeping with the overall goals of the AHEC. All of the programs were directed either by UCLA or UCSF. A considerable amount of effort went into the evaluation of the CSJV-AHEC. All of the results of the evaluation cannot be cited here because they are voluminous. Some specific results can be described, and these serve as tangible evidence of the success of this remarkable partnership between the University of California and the central San Joaquin Valley. Because of the development of cooperative institutional arrangements, the number of health personnel trained in csJv institutions has increased. In 1972, four programs were devoted to training approximately 41 health personnel. During the past four years of the AHEC, 12 programs trained approximately 550 health personnel. Of even greater significance is the fact that the University did not assume the responsibility for these programs, but that the AHEC served as the facilitator through which independent institutions in the valley could develop new programs and improve existing programs for the health professions. Except for some visiting consultants in medicine, there were no continuing education activities in the valley in 1972. During the five years of the AHEC, seven different types of programs trained approximately 33,230 health personnel. With federal financial support, the government's project and contract officers, the faculty of UCLA and UCSF, the institutions of higher education in the valley and the leadership of the com358
APRIL 1978 * 128 * 4
munity, the AHEC forged a relationship through which many of its health manpower goals have been achieved. Another result of the AHEC is the expansion of continuing education opportunities for all health personnel practicing in the six counties making up the AHEC area. Programs for dentists, nurses and a variety of other health personnel have been offered. Interdisciplinary continuing education programs have been organized, and in medicine a number of rural hospitals have organized themselves into consortia in order to develop a more coordinated valley-based continuing education effort. As part of the evaluation of the continuing education effort a sample of the valley's physicians was surveyed and the results showed that among physicians there is a universal feeling that the AHEC enhanced the professional environment of the area. While it cannot be assessed, it appears safe to assume that this improved professional environment should result in improved health care. Still another achievement, although not solely attributable to the AHEC, is the Medical Education Program developed by the School of Medicine, UCSF, and the Veterans Administration. The Medical Education Program is centered at the Fresno Veterans Administration Hospital and will be a branch of the UCSF School of Medicine. While creation of the Medical Education Program cannot be attributed exclusively to the AHEC, by granting the financial resources to the University for this program the Veterans Administration recognized that the AHEC had established the infrastructure upon which a medical education program could be developed. The implications of the Medical Education Program for the valley are significant. In time the program will have the capability to expand into rural areas, and will be able to attract and to retain in the valley a variety of health personnel, thereby enhancing further the initial achievements of the AHEC. As the Medical Education Program expands, it will build on the existing AHEC programs, and this partnership will ultimately lead to the development of outstanding rural and urban health care resources. It appears, however, that the greatest achievement of the AHEC is that it proved that a partnership between a university and a community is possible and desirable. The institutions that make up the AHEC all saw themselves as equal
AREA HEALTH EDUCATION CENTER
partners and worked toward common goals. In working together, the expectations of the Carnegie Commission report that the resources of university health sciences centers could be used to assist underserved communities have been realized. It was also the hope of the Carnegie Commission that universities would share equally with all the appropriate institutions of a community in meeting the community's health manpower and health care needs, and this hope has also been attained in the CSJV-AHEC. The success of the CSJV-AHEC can be attributed to a number of reasons. It was important that the University of California did not see itself as a monolith imposing itself on a community, but
viewed itself as an institution with a responsibility and commitment to education and health care. The alert leadership of the csJv community, on the other hand, recognized the potential of its own institutions in dealing with many of its health and health manpower problems, but appreciated the fact that outside resources were also needed. In harmony the University of California and the central San Joaquin Valley leadership worked diligently to develop the valley's resources in education and health care, thereby further enhancing the welfare of the valley as a community. REFERENCE 1. Carnegie Commission on Higher Education: Higher Education and the Nation's Health: Policies for Medical and Dental Education. San Francisco, McGraw-Hill, 1970
Malnutrition in Patients With Malignant Lesions of the Head and Neck MALNUTRITION frequently is at the root of complications occurring in patients with malignant lesions of the head and neck. And it has been proposed as the common denominator of the multiple complications which ultimately cause death in patients with major head and neck tumors. Dr. Paul Marx of Columbia University's Cancer Research Center recently commented that "Over half of all female cancer deaths and 30 percent of all male cancer deaths may be related to nutritional factors." Improved nutritional status is often a valuable complement to other therapeutic measures. For example, rats maintained on intravenous feedings could tolerate twice as much 5-fluorouracil as could control animals. Patients with head and neck malignancy are often considerably deficient nutritionally when first evaluated due to a combination of age, inadequate dietary intake, and associated disease such as alcoholism. Discomfort, ulceration, bleeding, infection, or difficulty with swallowing may already have produced a state of negative nitrogen balance. -DONALD
0.
CASTELL, MD, Bethesda
Extracted from A udio-Digest Otorhiniolarynigology, Vol. 10, No. 16, in the Audio-Digest Foundation's subscription series of taperecorded programs. For subscription information: 1577 East Chevy Chase Drive, Glendale, CA 91206.
THE WESTERN JOURNAL OF MEDICINE
359
Medical Education
The Central San Joaquin Valley Health Education Center
Area
EDWIN F. ROSINSKI, EdD, San Francisco
With federal financial support, an area health education center was established in the central San Joaquin Valley of California. The center is a cooperative health sciences education and health care program organized by the University of California and some of the educational and health care institutions of the valley. The center's goals include providing and improving primary health care education, and improving the distribution of health personnel. These goals are achieved through the cooperative development of a number of independent and interdependent activities. An extensive evaluation of the Area Health Education Center has shown that it is a highly effective program.
THE CARNEGIE COMMISSION ON HIGHER EDUCATION in its Report on Higher Education and the Nation's Health proposed the development of area health education centers (AHEC) as a means of developing health manpower in geographic areas without a university medical center. In making the proposal, the Carnegie Commission defined the role of an AHEC: ... centers would be affiliated with the nearest university health science center, and would perform somewhat the same functions recommended for university health sciences centers except that the education of MD and DDS candidates would be restricted to a limited amount of clinical education on a rotational basis, and research programs would be largely restricted to the evaluation of local experiments in health care delivery systems.'
As proposed by the Commission, the AHEC'S would essentially be extensions or satellites of Dr. Rosinski is Professor of Medical Education and Director, Office of Medical Education, University of California, San Francisco, School of Medicine. Reprint requests to: Edwin F. Rosinski, EdD, Office of Medical Education, UC, San Francisco, 50 Kirkham St., San Francisco, CA 94143.
university health science centers. The AHEC'S would be visited regularly by university faculty who would give lectures and seminars, attend clinics, make ward rounds and the like. Educational programs would be developed by the participating institutions in collaboration with the university faculty. As the AHEC's developed, they in turn would provide assistance to other community institutions and health care facilities. The AHEC concept had almost instant approval from most quarters of health sciences education. The federal government endorsed the AHEC concept because past experience indicated that university health centers could not respond, by themselves, to such pressing issues as geographic and specialty maldistribution of health personnel. It was believed that a consortium of institutionssecondary schools, community colleges, state colleges, universities, community hospitals and clinics, governmental and private agencies, voluntary health agencies, health professions organizaTHE WESTERN JOURNAL OF MEDICINE
355
AREA HEALTH EDUCATION CENTER
ABBREVIATIONS USED IN TEXT AHEC=area health education center CSJV=central San Joaquin Valley UCLA= University of California, Los Angeles UCSF=University of California, San Francisco VMC= Valley Medical Center
tions and others-working together, each contributing a unique resource in the development of health personnel programs, was an approach that had merit and should be tested. Legislation to support AHEC'S was developed and the Comprehensive Health Manpower Training Act of 1971 (Public Law 92-157) enacted by Congress made them a reality. Section 774A of that law suggested that a number of goals be established for federally supported AHEC'S. They included, among others, the following: identifying the need for health personnel; providing educational programs for medical students, residents and allied health personnel; providing continuing education programs for health personnel; developing resources in order to attract health personnel to medically underserved areas; coordinating health personnel training programs, and developing new health careers. To encourage the development of AHEC's, the federal government invited university health sciences centers to submit proposals on how they might initiate such programs in their areas. The federal invitations were in the form of a Request for Proposal (RFP) for contracts that would be critically reviewed and would be competitive. Funds were limited, consequently the initial number of AHEC's also would be limited. The schools of medicine of the University of California, San Francisco (UCSF) and Los Angeles (UCLA), viewed the AHEC concept as one means by which they could extend their resources to a medically underserved area in California, while at the same time assisting the area in the development of its own health sciences education and health care resources. While many areas in California might qualify as being "medically underserved," it was agreed that the central San Joaquin Valley (CsJv) had the potential to continue the development of its health sciences education and health care programs when university participation in the development and operation of the AHEC came to an end. The CSJV was an excellent place in which to locate and initiate an AHEC. For many years the 356
APRIL 1978
*
128
*
4
community had a strong interest in beginning a medical education activity and superb leadership was provided by a number of outstanding persons in the community. The community leadership organized itself into the Central San Joaquin Valley Health Consortium and the consortium had as its primary goal fostering the development of health sciences education in the area. Furthermore, the community had developed the groundwork for a program such as the AHEC through its involvement in a number of activities related to the former Regional Medical Program, and from the efforts to establish a modified AHEC approach through funding by the Veterans Administration at the Fresno Veterans Administration Hospital. It was an appropriate time for a joint effort between the medical schools and the csJv Health Consortium to launch a program that would expand and develop the valley's health sciences and health care resources. The schools of medicine at UCSF and UCLA were fully aware that it would be presumptuous to initiate unilaterally an AHEC in a community almost 250 miles away. Since the schools had good relations with the health consortium it was relatively easy to get the concerned parties together to develop AHEC proposals. Finally, both UCLA and UCSF prepared proposals, but the government decided that the two proposals should be combined, and awarded the contract to UCSF. The deans of both medical schools then decided which campus would be responsible for what, and the Central San Joaquin Valley AHEC-one of 11 area health education centers approved and funded in the country-began operation. The San Francisco campus was designated the prime contractor, while UCLA contracted to carry out certain activities and fulfilled its contractual obligations. For a project as large as the CSJV-AHEC, the administrative staff is remarkably small. The Project Director is the Associate Dean, Extended Programs in Medical Education at UCSF, and he has a full-time assistant who handles the day-today operation and supervises the staff, almost all of whom are located in Fresno. In addition, the position of Associate Director, UCLA, has been maintained to provide leadership for the UCLA activities. The Project Director has an advisory committee consisting of members of the AHEC community, and faculty members from UCLA and
AREA HEALTH EDUCATION CENTER
UCSF. The advisory committee meets at regular intervals to discuss and consider policy and, once a year, to select its own chairperson. Staff meetings, consisting primarily of the directors of each of the component programs, are held at irregular intervals. The purpose of the staff meetings is to keep everyone involved in the project informed about activities in each component program. Once a year the program directors submit their plans and budgets for the coming year to the Project Director and these plans are discussed at a staff meeting. The Project Director submits a budget to the Department of Health, Education, and Welfare where it is critically reviewed by the contract officer of the local Department of Health, Education, and Welfare Regional Office. An unusual feature of the AHEC legislation was the requirement that every program be evaluated. With the federal government increasingly concerned with accountability, the legislation clearly stipulated that evaluation should be a major activity of each AHEC. Sensitive. to the need for an impartial evaluation, the Project Director requested a number of persons to submit proposals to evaluate the program. One was selected and periodic reports are made to the Project Director on the progress of the entire project as well as the progress of each component program. A final report upon conclusion of the initial funding of the project essentially answered the question "Was it a success?" The CSJV-AHEC began on October 1, 1972. The AHEC is a series of independent and interdependent individual programs all directed toward achieving one or more of the goals of the national AHEC program, which are the following: (1) To improve the specialty and geographic distribution, supply, quality, utilization, and efficiency of health personnel in the health delivery system. (2) To improve the regional development of educational responsibilities of health professions schools. (3) To effect change in the distribution of health personnel and the accessibility to quality health care in the AHEC area. The AHEC began with 13 programs and during year five, the last year of the initial funding of the project, there were 23 programs. During the course of the five years a number of programs were discontinued because they did not meet either the goals of the AHEC or the program objectives. Other programs were ended because they had met all of their objectives, while others were added which in the judgment of the
Project Director and his advisory committee and the government were considered compatible with the overall goals of the AHEC. A brief description of some of the component programs should illustrate how the AHEC works. One of the more specific objectives of the AHEC is to provide and to improve primary health care education in the valley. The family medicine residency program is affiliated with the Division of Community and Ambulatory Medicine of the School of Medicine, UCSF, and is one of several programs working toward achieving that objective. The family medicine residency program carried out the following activities in the valley: (1) developed an affiliation between the Valley Medical Center (vMc) and UCSF; (2) developed community medicine rotations in rural patient care facilities; (3) developed medical student elective clerkships at vMc; (4) used faculty from UCSF and other university health science centers as teaching consultants to the VMC, and (5) provided lectures and seminars at the VMC for medical students, residents and private practitioners. Another program directed toward improving primary health care education is the video tapes program. Video tapes on primary medical care topics are developed by UCSF and made available to practitioners in the valley. The family medicine residency program and the video tapes programs are independent activities, but in many ways are interdependent because they are both directed toward providing and improving primary health care education. As can be seen in the family medicine residency program, all of the UCSF efforts are directed toward assisting existing institutions in the valley by strengthening their capabilities to provide primary medical care. At the same time, it is appreciated that there are a number of resources in the valley that can be tapped for the education of medical students and residents-or in bureaucratic jargon, UCSF has sought to develop "linkages" between its campus and institutions in the valley. A brief review of some of the other component programs should further illustrate how the entire project is geared toward achieving the three previously cited major goals of the national AHEC program. A drug information program provides drug information to health professionals on all aspects of drugs, drug therapy and drug toxicity. The biomedical library resources program had as its goal the improvement of biomedical resources and THE WESTERN JOURNAL OF MEDICINE
357
AREA HEALTH EDUCATION CENTER
information services. A health administrators program set out to upgrade the capabilities of rural health administrators. The pediatric nurse associate program first assessed whether there was a need for personnel of this type, and after determining that there was, began to develop an appropriate training program. The number of dental hygienists was increased through the development of the dental hygiene program at Fresno City College, and a program for training dental laboratory technicians was inaugurated at Merced Community College. A number of programs contained continuing education activities; these included medicine, dentistry, nursing and the allied health professions. One program had a rather specific objective and that was to promote the continuous improvement of services in the intensive care of patients. Perhaps while this program might not be considered primary medical care, it was felt that it was in keeping with the overall goals of the AHEC. All of the programs were directed either by UCLA or UCSF. A considerable amount of effort went into the evaluation of the CSJV-AHEC. All of the results of the evaluation cannot be cited here because they are voluminous. Some specific results can be described, and these serve as tangible evidence of the success of this remarkable partnership between the University of California and the central San Joaquin Valley. Because of the development of cooperative institutional arrangements, the number of health personnel trained in csJv institutions has increased. In 1972, four programs were devoted to training approximately 41 health personnel. During the past four years of the AHEC, 12 programs trained approximately 550 health personnel. Of even greater significance is the fact that the University did not assume the responsibility for these programs, but that the AHEC served as the facilitator through which independent institutions in the valley could develop new programs and improve existing programs for the health professions. Except for some visiting consultants in medicine, there were no continuing education activities in the valley in 1972. During the five years of the AHEC, seven different types of programs trained approximately 33,230 health personnel. With federal financial support, the government's project and contract officers, the faculty of UCLA and UCSF, the institutions of higher education in the valley and the leadership of the com358
APRIL 1978 * 128 * 4
munity, the AHEC forged a relationship through which many of its health manpower goals have been achieved. Another result of the AHEC is the expansion of continuing education opportunities for all health personnel practicing in the six counties making up the AHEC area. Programs for dentists, nurses and a variety of other health personnel have been offered. Interdisciplinary continuing education programs have been organized, and in medicine a number of rural hospitals have organized themselves into consortia in order to develop a more coordinated valley-based continuing education effort. As part of the evaluation of the continuing education effort a sample of the valley's physicians was surveyed and the results showed that among physicians there is a universal feeling that the AHEC enhanced the professional environment of the area. While it cannot be assessed, it appears safe to assume that this improved professional environment should result in improved health care. Still another achievement, although not solely attributable to the AHEC, is the Medical Education Program developed by the School of Medicine, UCSF, and the Veterans Administration. The Medical Education Program is centered at the Fresno Veterans Administration Hospital and will be a branch of the UCSF School of Medicine. While creation of the Medical Education Program cannot be attributed exclusively to the AHEC, by granting the financial resources to the University for this program the Veterans Administration recognized that the AHEC had established the infrastructure upon which a medical education program could be developed. The implications of the Medical Education Program for the valley are significant. In time the program will have the capability to expand into rural areas, and will be able to attract and to retain in the valley a variety of health personnel, thereby enhancing further the initial achievements of the AHEC. As the Medical Education Program expands, it will build on the existing AHEC programs, and this partnership will ultimately lead to the development of outstanding rural and urban health care resources. It appears, however, that the greatest achievement of the AHEC is that it proved that a partnership between a university and a community is possible and desirable. The institutions that make up the AHEC all saw themselves as equal
AREA HEALTH EDUCATION CENTER
partners and worked toward common goals. In working together, the expectations of the Carnegie Commission report that the resources of university health sciences centers could be used to assist underserved communities have been realized. It was also the hope of the Carnegie Commission that universities would share equally with all the appropriate institutions of a community in meeting the community's health manpower and health care needs, and this hope has also been attained in the CSJV-AHEC. The success of the CSJV-AHEC can be attributed to a number of reasons. It was important that the University of California did not see itself as a monolith imposing itself on a community, but
viewed itself as an institution with a responsibility and commitment to education and health care. The alert leadership of the csJv community, on the other hand, recognized the potential of its own institutions in dealing with many of its health and health manpower problems, but appreciated the fact that outside resources were also needed. In harmony the University of California and the central San Joaquin Valley leadership worked diligently to develop the valley's resources in education and health care, thereby further enhancing the welfare of the valley as a community. REFERENCE 1. Carnegie Commission on Higher Education: Higher Education and the Nation's Health: Policies for Medical and Dental Education. San Francisco, McGraw-Hill, 1970
Malnutrition in Patients With Malignant Lesions of the Head and Neck MALNUTRITION frequently is at the root of complications occurring in patients with malignant lesions of the head and neck. And it has been proposed as the common denominator of the multiple complications which ultimately cause death in patients with major head and neck tumors. Dr. Paul Marx of Columbia University's Cancer Research Center recently commented that "Over half of all female cancer deaths and 30 percent of all male cancer deaths may be related to nutritional factors." Improved nutritional status is often a valuable complement to other therapeutic measures. For example, rats maintained on intravenous feedings could tolerate twice as much 5-fluorouracil as could control animals. Patients with head and neck malignancy are often considerably deficient nutritionally when first evaluated due to a combination of age, inadequate dietary intake, and associated disease such as alcoholism. Discomfort, ulceration, bleeding, infection, or difficulty with swallowing may already have produced a state of negative nitrogen balance. -DONALD
0.
CASTELL, MD, Bethesda
Extracted from A udio-Digest Otorhiniolarynigology, Vol. 10, No. 16, in the Audio-Digest Foundation's subscription series of taperecorded programs. For subscription information: 1577 East Chevy Chase Drive, Glendale, CA 91206.
THE WESTERN JOURNAL OF MEDICINE
359
