1586
DESIGNING A DOCTOR
The dominance of research in staffing of medical schools: time for a change?
There is little incentive for anyone to write on a topic so provocative. The title alone puts the author at risk on two counts. First, is there truly anything wrong with a "dominance of research in staffing of medical schools"? Research is, after all, valued above anything else in medical education. Second, why would we ever want to "change" anything? The present system is producing splendid physicians and surgeons. Thus, anyone suggesting that the present system might profit from even a review, let alone "change", risks ostracism. It is rank heresy to consider action even perceived as downplaying or denigrating research. One interesting question, of course, is how did we ever get to this stage. The next few paragraphs speak to that point, with a focus on the United States but with an assumption that the events that are cited were paralleled in other developed countries. A little history
Medical schools at one time had a clear, undisputed, single-minded purpose of preparing young people for the practice of medicine. Research activities on the part of faculty may have been encouraged, but faculty were known for their expertise in medical practice. Teachers were expected to help their students learn the basic sciences and the application of those basic sciences to the practice of medicine. Deans and professors alike were selected for excellence in practice and excellence in educational processes, and this custom prevailed right up to World War II. In the United States, the growth of the National Institutes of Health (NIH) following the end of the war was accompanied by an unprecedented explosion of knowledge in the basic sciences-a phenomenon that led medical schools to rely increasingly on specialists in the basic sciences for the teaching of those disciplines. Of itself, that action seemed to be appropriate and beneficial to education. And those new teachers did spend time with students and seemed dedicated to excellence in education. But at the same time, the extramural funding programme of the NIH grew apace and American medical schools became more and more dependent upon the research funding provided to them by the NIH. It did not seem untoward for basic science departments in the 1960s and 1970s to come to rely on the NIH for up to 80% of their support. Indeed, in my travels to American medical schools in those days, I heard more than one distinguished dean acknowledge that level of support saying "We must simply look upon this as ’hard money"’ (ie, university support). Thus, medical schools became dependent upon substantial subsidy-provided to basic science departments, not to the school itself. From all of that grew a national ethos which values research and its trappings-publication and grantsmanship.
These have become the academic medium of exchange; that is, basic-science teachers fmd their personal careers (interinstitutional recognition and career mobility) tied inextricably to their ability to obtain research grants and to publish in high-prestige journals. Thus, it is no surprise to find that the central values of a medical faculty reside in the publish-or-perish world of the scientists rather than in dedication to education of the medical students.
Current problems
Every major review of American medical education since World War II has "discovered" and described the same problems. The best single statement is in the Report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine (GPEP) of the Association of American Colleges (AAMC).l The problems include (1) too much emphasis on memorisation of facts, (2) too little continuity within medical education; (3) too much reliance on multiple-choice-question testing; (4) too much lecturing; (5) not enough small-group learning activities; (6) not enough emphasis on problem-solving; and (7) not enough faculty involvement in educational endeavours. The recommendations included some dramatic departures from what is conventional. Of particular note, the report recommended that each medical school provide a budget dedicated to the management scheme so as to remove control of the curriculum from departmental domination. Needless to say, those recommendations were heartily rejected by the Council of Academic Societies of the AAMC-a council that includes chairmen of academic departments in American medical schools. They are obviously reluctant to lose their control of both the curriculum and, more importantly, the budget which in the GPEP report is recommended to be "dedicated" to medical education. Of possible relevance in this picture is what has happened to the time commitments of the basic-science teachers. Thirty years ago, teachers in the basic sciences were expected not only to give lectures, but also to monitor student learning activities during laboratory exercises. Over the past three decades, however, many of those laboratory learning experiences have been eliminated, one by one, and the most used method of education is now lecturing. Moreover, with the explosive increase in knowledge bases, lectures have been distributed more widely among specialists (whose major commitment is to their research) ADDRESS Department of Medical Education, University of Southern California School of Medicine, 1975 Zonal Ave, KAM 200, Los Angeles, LA 90033, USA (Prof S. Abrahamson, PhD)
1587
TABLE I-NUMBER OF HOURS OF TEACHING IN FOUR DEPARTMENTS
with the result that students do not get to know-or get to be known by-teachers in the medical school. In one medical school, for example, first-year medical students were lectured to by 136 different faculty members; in that same school, second-year medical students attended lectures given by 183 different teachers. In a survey conducted in one medical school, the actual number of faculty "contact hours" with students was tabulated. Table I shows the distribution of time spent by faculty of four basic-science departments in teaching medical students during the academic year. In that same survey, the size of the faculty-only those supported by medical-school funds, not by outside research grants or contracts-was also recorded, making possible a simple ratio of total number of teaching hours (of all faculty, both university-supported and supported on outside grants and contracts) divided by the number of faculty members paid from university funds (referred to as "full-time equivalent"). Table II shows these data. (Note that the ratios would be even smaller if the denominator-number of faculty-included all faculty and not just those supported on
university funds.) Now it is true that scholarship is a primary value of the university. And it is equally true that scholarship is often equated with research or, worse than that, the visible evidence of research-publication, presentation at national meetings, or certain other clear signs (grants). But should the faculty of a medical school-with its unique mission of preparing young people for the practice of medicinedevote so little time to teaching? And should the medical school-with its unique mission of preparing young people for the practice of medicine-be expected to support faculty virtually full time to do research? These data are not unique to that one medical school, although figures might vary somewhat. The fact of the matter is that the distribution of teaching hours by faculty members in the basic sciences is a clear reflection of the value system of the academic medical centre: doing one’s own research (and dissemination through publication or national meetings) holds top priority; participating in activities of one’s own discipline is another priority area; guiding one’s graduate students or fellows is still another; and somewhere at the bottom of the priority list is the education of medical students. And, frankly, one cannot fault these teachers: their personal futures, thanks to the national ethos, depend upon that approach to their professional/academic lives. However, the picture is not all that simple. The problem is exacerbated by the reluctance of the medical-school departments to relinquish control--either of the budget or of the curriculum. It is indeed a paradox that many basic-science teachers openly express their aversion to spending time with medical students ("this interferes with my research") and yet oppose introduction of a system that would entail interdisciplinary control of education with a budget dedicated to that endeavour. Their spirited defence of the status quo includes invocation of one of Abrahamson’s
TABLE II-NUMBER OF UNIVERSITY-PAID FACULTY AND TEACHING HOURS BY ALL FACULTY BY DEPARTMENT
FTE=full-time
equivalent.
shibboleths of medical education: "To be a ’good teacher’ 112 Indeed, while the best of all possible education worlds might very well be having teachers who are outstanding in their research as well as highly skilled in educational techniques and truly interested in medical students and in medical education, the fact of the matter is that there is a "zero correlation" between excellence in teaching and excellence in research. One may be a brilliant investigator and a poor teacher; another may be a poor investigator and an excellent teacher; or one may be excellent in both-or poor in both. It is time for us to acknowledge that curriculum development in a medical school is not logical or even educational; it is political and emotional.3 It is, therefore, time for us to recognise that improvement of medical education cannot be achieved by reasoned discussions and review of data obtained through educational research. An all-too-familiar response to research data concerning teaching and learning in medical schools is the old wheeze, "My mind is made up; don’t try to confuse me with facts". The facts are often disturbing to the status quo and thus rejected-usually along with the person presenting them, incidentally. In one medical school, just recently, the executive committee was considering the possibility of introducing (as an educational experiment) a problem-based curriculum for 24 students (of the entering class of 136). Members of the executive committee received summaries of the evaluative research available from several medical schools in which there was a problem-based curriculum. Even after several hour-long discussions, someone asked, "Well, do we know whether this curriculum really works?". Furthermore, when it was pointed out that McMaster had been using such an approach for twenty years, the question was still asked: "But does this curriculum really work?". one must be active in research.
The solution? It is time for a change-not necessarily of curriculum, but of the way in which curriculum is governed. It is time for a change in the control of the curriculum-not with any intent to disenfranchise the faculty, but rather with the intent to re-enfranchise the faculty. It is time for a change in the way in which the education of medical students is financed. But these ideas need some elaboration. The day of the "triple-threat" academician is over. It is really no longer possible for a faculty member to excel in research and in teaching and in service-the three familiar performance areas in which faculty are judged. There may be a very occasional "renaissance" man (or woman) who meets criteria in all three areas, but for the most part it just is no longer possible. Thus, the medical school should shift its demands and now expect a given academic department to excel in all three areas, with different members of that
1588
department expected to excel in various combinations of the areas of performance. Starting with that major premise, we now need to
three
examine the governance of a medical school with an eye toward creating a new approach which will be more responsive to the needs of students and of the curriculum. Consider a previous utterance of mine: "The question becomes: What can we do about the situation? The educators among us keep complaining about things that we cannot change: criteria for selection and/or promotion of faculty; the value structure of the world of biomedical sciences-in other words, the national ethos of medical education. In addition, the educators among us seem afraid to consider things we can change: governance of the medical school; control of the budget; cost accountability for educational efforts".’
What is needed is a change in control of medical education. What is needed is a change in the administration of medical education. What is needed is a change in the financing of medical education. Such changes are unlikely to be achieved without a political and emotional struggle-but that is what curriculum planning in a medical school is all about anyway. Imagine a situation in which central control resides in an administrative official who controls the budget for education. He or she would be in a position to negotiate with department chairs with regard to programme needs for faculty time. The chairperson would be able to indicate whether the teaching has been of the quality that warrants the same level of support or whether there needs to be improvement in the teaching. Or the chairperson would be able to determine whether there has been enough time spent
in educational planning or in counselling of students to warrant the same level of support in the future. Such actions, however, can come only with careful design of the budget to reflect an independence from other activities-eg, research, patient care, grantsmanship, and/or publication. In other words, go back to the GPEP recommendation, a budget dedicated to the support of medical education and a special interdisciplinary management scheme. There is nothing very radical in this concept. Curriculum may or may not change; innovation may or may not be introduced; teaching methods may or may not changebecause the curriculum does and should belong to the faculty. The change will be in faculty attitudes toward teaching, in faculty participation in teaching, and in the quality of that
participation. It is time for
a
change: it is
time
to
reorganise
the
governance of medical education so that faculty in control of
education
responsibility,
for and interested in that serious responsibility.
prepared
are
for it is
a
REFERENCES 1. Muller S.
Physicians for the twenty-first century. J Med Educ 1984; 59:
part 2.
Myths and shibboleths in medical education. Teaching Learning Med 1988; 1: no. 1.
2. Abrahamson S.
3. Abrahamson S. Offices of research in medical education. Invited review at the twenty-ninth Annual RIME Conference, Association of American Medical Colleges, San Francisco, 1990. 4. Abrahamson S. The state of American education. Teaching Learning Med 1990; 2: no 3: 120-25.
VIEWPOINT Health needs, health-care requirements, and the myth of infinite demand
NHS reforms in the UK, which particularly forceful response to this global represent of perception a crisis in health care,l have been made largely in response to the political problems presented by failure to satisfy health-care demands as identified in long waiting lists. After forty years the waiting list tail-a device for offering nominal access to treatments which may never be delivered-has finally wagged the entire NHS dog. Instead of identifying all demand, but rationing access to it, the reformed NHS has at its core the innovation that health-care providers’ capacity to offer treatments is to be made explicit. According to the white-paper, Working for Patients, health authorities are to be relieved of direct responsibility for treatment facilities so that they may "concentrate on ensuring that the health needs of the population for which they are responsible are met".
ideal of health-care provision based on prior assessment of health needs has long been aspired to by health-care planners. But what is need? In common use, the term has two distinct meanings: circumstances in which a thing/ course of action is required; or lack of necessaries, poverty. The semantic tension between the first neutral meaning, a requirement, and the second moral meaning, a situation of great difficulty or misfortune, lies at the heart of the difficulties faced when deciding what needs should be assessed, how they should be assessed, and whether and when any action should follow that assessment. The conventional form of needs analysis derives from the work of Engels, Dickens, Chadwick, Wakley, Charles Booth, Seebohm Rowntree, and other social reformers in the nineteenth century. The dominant view of need and needs assessment can be followed from the exposure of appalling social conditions by the poor-law reformers, through the more sophisticated studies of poverty and health that concerned the originators of the welfare state, to
Assessment of health needs
ADDRESS
Whatever the practicalities involved in the redirection of a health system as large and complex as the whole NHS, the
Epidemiology and Public Health Medicine, University of Bristol, Bristol BS8 2PR, UK (S. Frankel, DM).
The
increasing costs of modem health care, allied to widespread economic pessimism, have led health policymakers world wide to emphasise retrenchment and cost control. The
current
a
Health Care
Evaluation
Unit, Department of
DESIGNING A DOCTOR
The dominance of research in staffing of medical schools: time for a change?
There is little incentive for anyone to write on a topic so provocative. The title alone puts the author at risk on two counts. First, is there truly anything wrong with a "dominance of research in staffing of medical schools"? Research is, after all, valued above anything else in medical education. Second, why would we ever want to "change" anything? The present system is producing splendid physicians and surgeons. Thus, anyone suggesting that the present system might profit from even a review, let alone "change", risks ostracism. It is rank heresy to consider action even perceived as downplaying or denigrating research. One interesting question, of course, is how did we ever get to this stage. The next few paragraphs speak to that point, with a focus on the United States but with an assumption that the events that are cited were paralleled in other developed countries. A little history
Medical schools at one time had a clear, undisputed, single-minded purpose of preparing young people for the practice of medicine. Research activities on the part of faculty may have been encouraged, but faculty were known for their expertise in medical practice. Teachers were expected to help their students learn the basic sciences and the application of those basic sciences to the practice of medicine. Deans and professors alike were selected for excellence in practice and excellence in educational processes, and this custom prevailed right up to World War II. In the United States, the growth of the National Institutes of Health (NIH) following the end of the war was accompanied by an unprecedented explosion of knowledge in the basic sciences-a phenomenon that led medical schools to rely increasingly on specialists in the basic sciences for the teaching of those disciplines. Of itself, that action seemed to be appropriate and beneficial to education. And those new teachers did spend time with students and seemed dedicated to excellence in education. But at the same time, the extramural funding programme of the NIH grew apace and American medical schools became more and more dependent upon the research funding provided to them by the NIH. It did not seem untoward for basic science departments in the 1960s and 1970s to come to rely on the NIH for up to 80% of their support. Indeed, in my travels to American medical schools in those days, I heard more than one distinguished dean acknowledge that level of support saying "We must simply look upon this as ’hard money"’ (ie, university support). Thus, medical schools became dependent upon substantial subsidy-provided to basic science departments, not to the school itself. From all of that grew a national ethos which values research and its trappings-publication and grantsmanship.
These have become the academic medium of exchange; that is, basic-science teachers fmd their personal careers (interinstitutional recognition and career mobility) tied inextricably to their ability to obtain research grants and to publish in high-prestige journals. Thus, it is no surprise to find that the central values of a medical faculty reside in the publish-or-perish world of the scientists rather than in dedication to education of the medical students.
Current problems
Every major review of American medical education since World War II has "discovered" and described the same problems. The best single statement is in the Report of the Panel on the General Professional Education of the Physician and College Preparation for Medicine (GPEP) of the Association of American Colleges (AAMC).l The problems include (1) too much emphasis on memorisation of facts, (2) too little continuity within medical education; (3) too much reliance on multiple-choice-question testing; (4) too much lecturing; (5) not enough small-group learning activities; (6) not enough emphasis on problem-solving; and (7) not enough faculty involvement in educational endeavours. The recommendations included some dramatic departures from what is conventional. Of particular note, the report recommended that each medical school provide a budget dedicated to the management scheme so as to remove control of the curriculum from departmental domination. Needless to say, those recommendations were heartily rejected by the Council of Academic Societies of the AAMC-a council that includes chairmen of academic departments in American medical schools. They are obviously reluctant to lose their control of both the curriculum and, more importantly, the budget which in the GPEP report is recommended to be "dedicated" to medical education. Of possible relevance in this picture is what has happened to the time commitments of the basic-science teachers. Thirty years ago, teachers in the basic sciences were expected not only to give lectures, but also to monitor student learning activities during laboratory exercises. Over the past three decades, however, many of those laboratory learning experiences have been eliminated, one by one, and the most used method of education is now lecturing. Moreover, with the explosive increase in knowledge bases, lectures have been distributed more widely among specialists (whose major commitment is to their research) ADDRESS Department of Medical Education, University of Southern California School of Medicine, 1975 Zonal Ave, KAM 200, Los Angeles, LA 90033, USA (Prof S. Abrahamson, PhD)
1587
TABLE I-NUMBER OF HOURS OF TEACHING IN FOUR DEPARTMENTS
with the result that students do not get to know-or get to be known by-teachers in the medical school. In one medical school, for example, first-year medical students were lectured to by 136 different faculty members; in that same school, second-year medical students attended lectures given by 183 different teachers. In a survey conducted in one medical school, the actual number of faculty "contact hours" with students was tabulated. Table I shows the distribution of time spent by faculty of four basic-science departments in teaching medical students during the academic year. In that same survey, the size of the faculty-only those supported by medical-school funds, not by outside research grants or contracts-was also recorded, making possible a simple ratio of total number of teaching hours (of all faculty, both university-supported and supported on outside grants and contracts) divided by the number of faculty members paid from university funds (referred to as "full-time equivalent"). Table II shows these data. (Note that the ratios would be even smaller if the denominator-number of faculty-included all faculty and not just those supported on
university funds.) Now it is true that scholarship is a primary value of the university. And it is equally true that scholarship is often equated with research or, worse than that, the visible evidence of research-publication, presentation at national meetings, or certain other clear signs (grants). But should the faculty of a medical school-with its unique mission of preparing young people for the practice of medicinedevote so little time to teaching? And should the medical school-with its unique mission of preparing young people for the practice of medicine-be expected to support faculty virtually full time to do research? These data are not unique to that one medical school, although figures might vary somewhat. The fact of the matter is that the distribution of teaching hours by faculty members in the basic sciences is a clear reflection of the value system of the academic medical centre: doing one’s own research (and dissemination through publication or national meetings) holds top priority; participating in activities of one’s own discipline is another priority area; guiding one’s graduate students or fellows is still another; and somewhere at the bottom of the priority list is the education of medical students. And, frankly, one cannot fault these teachers: their personal futures, thanks to the national ethos, depend upon that approach to their professional/academic lives. However, the picture is not all that simple. The problem is exacerbated by the reluctance of the medical-school departments to relinquish control--either of the budget or of the curriculum. It is indeed a paradox that many basic-science teachers openly express their aversion to spending time with medical students ("this interferes with my research") and yet oppose introduction of a system that would entail interdisciplinary control of education with a budget dedicated to that endeavour. Their spirited defence of the status quo includes invocation of one of Abrahamson’s
TABLE II-NUMBER OF UNIVERSITY-PAID FACULTY AND TEACHING HOURS BY ALL FACULTY BY DEPARTMENT
FTE=full-time
equivalent.
shibboleths of medical education: "To be a ’good teacher’ 112 Indeed, while the best of all possible education worlds might very well be having teachers who are outstanding in their research as well as highly skilled in educational techniques and truly interested in medical students and in medical education, the fact of the matter is that there is a "zero correlation" between excellence in teaching and excellence in research. One may be a brilliant investigator and a poor teacher; another may be a poor investigator and an excellent teacher; or one may be excellent in both-or poor in both. It is time for us to acknowledge that curriculum development in a medical school is not logical or even educational; it is political and emotional.3 It is, therefore, time for us to recognise that improvement of medical education cannot be achieved by reasoned discussions and review of data obtained through educational research. An all-too-familiar response to research data concerning teaching and learning in medical schools is the old wheeze, "My mind is made up; don’t try to confuse me with facts". The facts are often disturbing to the status quo and thus rejected-usually along with the person presenting them, incidentally. In one medical school, just recently, the executive committee was considering the possibility of introducing (as an educational experiment) a problem-based curriculum for 24 students (of the entering class of 136). Members of the executive committee received summaries of the evaluative research available from several medical schools in which there was a problem-based curriculum. Even after several hour-long discussions, someone asked, "Well, do we know whether this curriculum really works?". Furthermore, when it was pointed out that McMaster had been using such an approach for twenty years, the question was still asked: "But does this curriculum really work?". one must be active in research.
The solution? It is time for a change-not necessarily of curriculum, but of the way in which curriculum is governed. It is time for a change in the control of the curriculum-not with any intent to disenfranchise the faculty, but rather with the intent to re-enfranchise the faculty. It is time for a change in the way in which the education of medical students is financed. But these ideas need some elaboration. The day of the "triple-threat" academician is over. It is really no longer possible for a faculty member to excel in research and in teaching and in service-the three familiar performance areas in which faculty are judged. There may be a very occasional "renaissance" man (or woman) who meets criteria in all three areas, but for the most part it just is no longer possible. Thus, the medical school should shift its demands and now expect a given academic department to excel in all three areas, with different members of that
1588
department expected to excel in various combinations of the areas of performance. Starting with that major premise, we now need to
three
examine the governance of a medical school with an eye toward creating a new approach which will be more responsive to the needs of students and of the curriculum. Consider a previous utterance of mine: "The question becomes: What can we do about the situation? The educators among us keep complaining about things that we cannot change: criteria for selection and/or promotion of faculty; the value structure of the world of biomedical sciences-in other words, the national ethos of medical education. In addition, the educators among us seem afraid to consider things we can change: governance of the medical school; control of the budget; cost accountability for educational efforts".’
What is needed is a change in control of medical education. What is needed is a change in the administration of medical education. What is needed is a change in the financing of medical education. Such changes are unlikely to be achieved without a political and emotional struggle-but that is what curriculum planning in a medical school is all about anyway. Imagine a situation in which central control resides in an administrative official who controls the budget for education. He or she would be in a position to negotiate with department chairs with regard to programme needs for faculty time. The chairperson would be able to indicate whether the teaching has been of the quality that warrants the same level of support or whether there needs to be improvement in the teaching. Or the chairperson would be able to determine whether there has been enough time spent
in educational planning or in counselling of students to warrant the same level of support in the future. Such actions, however, can come only with careful design of the budget to reflect an independence from other activities-eg, research, patient care, grantsmanship, and/or publication. In other words, go back to the GPEP recommendation, a budget dedicated to the support of medical education and a special interdisciplinary management scheme. There is nothing very radical in this concept. Curriculum may or may not change; innovation may or may not be introduced; teaching methods may or may not changebecause the curriculum does and should belong to the faculty. The change will be in faculty attitudes toward teaching, in faculty participation in teaching, and in the quality of that
participation. It is time for
a
change: it is
time
to
reorganise
the
governance of medical education so that faculty in control of
education
responsibility,
for and interested in that serious responsibility.
prepared
are
for it is
a
REFERENCES 1. Muller S.
Physicians for the twenty-first century. J Med Educ 1984; 59:
part 2.
Myths and shibboleths in medical education. Teaching Learning Med 1988; 1: no. 1.
2. Abrahamson S.
3. Abrahamson S. Offices of research in medical education. Invited review at the twenty-ninth Annual RIME Conference, Association of American Medical Colleges, San Francisco, 1990. 4. Abrahamson S. The state of American education. Teaching Learning Med 1990; 2: no 3: 120-25.
VIEWPOINT Health needs, health-care requirements, and the myth of infinite demand
NHS reforms in the UK, which particularly forceful response to this global represent of perception a crisis in health care,l have been made largely in response to the political problems presented by failure to satisfy health-care demands as identified in long waiting lists. After forty years the waiting list tail-a device for offering nominal access to treatments which may never be delivered-has finally wagged the entire NHS dog. Instead of identifying all demand, but rationing access to it, the reformed NHS has at its core the innovation that health-care providers’ capacity to offer treatments is to be made explicit. According to the white-paper, Working for Patients, health authorities are to be relieved of direct responsibility for treatment facilities so that they may "concentrate on ensuring that the health needs of the population for which they are responsible are met".
ideal of health-care provision based on prior assessment of health needs has long been aspired to by health-care planners. But what is need? In common use, the term has two distinct meanings: circumstances in which a thing/ course of action is required; or lack of necessaries, poverty. The semantic tension between the first neutral meaning, a requirement, and the second moral meaning, a situation of great difficulty or misfortune, lies at the heart of the difficulties faced when deciding what needs should be assessed, how they should be assessed, and whether and when any action should follow that assessment. The conventional form of needs analysis derives from the work of Engels, Dickens, Chadwick, Wakley, Charles Booth, Seebohm Rowntree, and other social reformers in the nineteenth century. The dominant view of need and needs assessment can be followed from the exposure of appalling social conditions by the poor-law reformers, through the more sophisticated studies of poverty and health that concerned the originators of the welfare state, to
Assessment of health needs
ADDRESS
Whatever the practicalities involved in the redirection of a health system as large and complex as the whole NHS, the
Epidemiology and Public Health Medicine, University of Bristol, Bristol BS8 2PR, UK (S. Frankel, DM).
The
increasing costs of modem health care, allied to widespread economic pessimism, have led health policymakers world wide to emphasise retrenchment and cost control. The
current
a
Health Care
Evaluation
Unit, Department of
