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THE ROLE OF A MEDICAL SCHOOL IN THE ORGANIZATION OF HEALTH-CARE SERVICES* SAMUEL J. BOSCH, M.D. Associate Professor and Deputy Chairman
KURT W. DEUSCHLE, M.D. Ethel Wise Professor of Community Medicine and Chairman Department of Community Medicine The Mount Sinai School of Medicine of the City University of New York New York, N.Y.
IN A VARIETY of ways society is demanding participation from the I medical schools in the solution of pressing problems of national and community health. The United States Congress and state and municipal governments, joined by social health agencies and organizations, are forcing more community-health-directed goals on academic medical centers. They are goading medical schools into action, commitment, and leadership by rewarding compliant institutions with federal, state, and municipal funds. ' The medical schools themselves are increasingly recognizing that they have some responsibility to respond to these pressures, particularly as they relate to changes required in manpower and the organization of the healthcare system. To judge by the increasing frequency with which publications on those matters have been appearing, the subject undoubtedly is of more than temporary interest. Outstanding medical statesmen throughout the world have appealed repeatedly to the academic leadership in medicine to accept a more active role in social health.
APPEALS FOR A CHANGE IN SOCIAL ROLE
Marcelino Candau, as general director of the World Health Organization, reviewed in 1966, at the Third World Conference on Medical Education, the effects that social change and scientific advances would have upon the social obligations of medicine.2 In the same year John Gardner *Presented as part of a Symposium on the Medical School and Its Surrounding Community held by the Committee on Medical Education of the New York Academy of Medicine October 14, 1976. Presented in part as the Merrimon Lecture in Medicine at the School of Medicine, University of North Carolina, Chapel Hill, N.C., October 15, 1975.
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called for every great university "to balance its responsibilities to the worlds of reflection and action" and asserted that both "detached scientists and those who will become involved in the world of action are essential to a society that aspires to creativity." 3 P.J. Sanazaro, commenting on the sudden emphasis on quality of care, argued for new responsibilities for direct involvement in the medical care system by the medical centers.4 Hans Popper, as one of the founders of the Mount Sinai School of Medicine in New York, asserted that the major goal of new and old medical schools should be to produce physicians whose training will be consonant with the future needs of society.5 Meanwhile, the same issues were being raised in other countries. In Latin America, Gabriel Velazquez was urging the involvement of academic medical centers in new types of research that would lead to the development of well-organized regional and national health-care systems,6 and the Pan American Federation of Associations of Medical Schools advocated the bringing together of medical schools and the social security health systems.7 More recently, J. T. English, commenting on the many serious inadequacies of our health services, requested that "new organizational models for health care delivery be supported, studied, and compared and that, in order to be sure that the vast talent of the nation's medical schools contributes to these efforts, departments of social and community medicine be supported.' '8 J. Cooper asserted that "the extension of federal involvement in health will focus more attention on every segment of the system, including the priorities and programs of the academic medical centers." He expects an increase in federal pressure-probably through the mechanism of financing-to result in extending the responsibility of the academic medical center for the provision of health care.9 R. H. Ebert stated that "the schools are under pressure to experiment with the medical care system to put more emphasis on ambulatory care and comprehensive care, provide primary care for communities adjacent to teaching hospitals and participate in regional planning."10 According to V. Navarro, "Our medical schools will have to realize that their parochial and mechanistic approach to medicine must be broadened; that they must recognize that the health of our people depends primarily on methods directed at populations rather than at individuals." He asserted that "some changes are in fact occurring, with medical schools now taking direct responsibility for the care of population besides individuals." '11 These appeals have stimulated much debate over where to draw the line for the social responsibility of the academic centers regarding, for examBull. N.Y. Acad. Med.
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ple, such an important issue as the organization and provision of health care.12-14 The enormous social and ecological problems of big cities exaggerate even further the challenge of determining where the academic medical centers can mark their legitimate boundaries of responsibility and accountability in this matter. In New York City, with a population of about eight million people and seven major medical schools, the issue of community commitment is extremely volatile. This issue is especially volatile in a new and evolving urban medical school such as the Mount Sinai School of Medicine of the City University of New York in upper Manhattan. The purpose of this paper is to present and analyze the role and responsibilities that the Department of Community Medicine of the Mount Sinai School of Medicine has assumed with respect to the organization of health-care delivery in East Harlem, its contiguous community.
THE SOCIAL COMMITMENT OF MOUNT SINAI The Mount Sinai School of Medicine of the City University of New York, founded in 1966 and opened in 1968, represents the union of a large voluntary hospital and a public university, each renowned for its longstanding pursuit of excellence. From the outset the founders of the medical school made the identification and solution of community health problems a clear institutional goal. They reasoned that this social commitment would be meaningless if it were not translated into a full-time faculty of community health scientists working side by side on a daily basis with the basic scientists and clinical faculty of the medical center. They therefore established a generously endowed Department of Community Medicine, envisioning it as an essential resource for contemporary medical education, research, and service.'5 Today the Department of Community Medicine is organized as a large, interdisciplinary "third faculty" of the medical school that complements the basic and clinical sciences faculties.* One of the department's principal mandates is to serve as a bridge between the resources of the medical center and those of the surrounding community, East Harlem, in a joint problem-solving effort.
THE SURROUNDING COMMUNITY East Harlem is located in the northeast corner of Manhattan, north of 96th Street and east of Fifth Avenue. During the early 1900s it was the *The approximately 50 full-time and 100 part-time faculty of the department represent the following major disciplines: behavioral science, environmental science, epidemiology, health economics, nursing, medicine, and social work.
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home of Italian and Jewish immigrant workers. Today the demographic picture has changed, and people of Puerto Rican origin make up 45% of the population, blacks another 35%, whites of direct European ancestry 17%, and "others" 3%. 16 The area, always inhabited by relatively low income groups, has deteriorated into the kind of ghetto area for which New York is infamous. Many of the households have no income from employment, and most of those who work hold low-paying jobs. Social problems and a high level of morbidity characterizes the population. In 1968 the East Harlem community was in a high fever of frustration and anger over the many inequities that plague the inner cities. There were angry confrontations over health-care services. Community demands transcended what the establishment considered legitimate medical-care concerns. Health-related issues in employment, housing, education, transportation, and security became entangled with the more medically oriented issues of the hospital and the clinic. There was antagonism between blacks and Puerto Ricans for political power and leadership roles with regard to the various community issues, including health. However, many community organizations were working to improve conditions, and there is evidence that their efforts have been and will continue to be productive. Our 1970 survey shows that the different ethnic groups within East Harlem have identified a common set of problems and have set priorities for dealing with them. 16 STRATEGIES AND POLICY One priority of the Department of Community Medicine was to learn how the Mount Sinai medical center could assist in improving health in East Harlem. The initial strategy was to establish a solid base of information about health in the community and to make existing community groups (consumers and providers of care) aware that a new resource for health was becoming available in the area. It soon became apparent that we could not simply wait for these groups to come to us with problems. An early Department of Health, Education, and Welfare grant enabled us to cooperate with the East Harlem Health Council (EHHC), a communitywide health group that included both consumers and providers of health care in the area. It was agreed that we needed an unbiased assessment of the health situation, as opposed to a possible potpourri of health demands based on priorities stemming from special-interest groups. Our decision to undertake a household survey proved to be a significant Bull. N.Y. Acad. Med.
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step in our relation with the community. All plans for the survey were reviewed with representatives of the community through the EHHC. Questionnaires were written in Spanish as well as English, and each question was pretested for the effectiveness of the communication. Then a 2% straight probability sample of households was selected; a survey of 78% of the sample was completed. Because our survey was carried out in 1970, our data could be compared with information derived from the United States census. Valuable insights were gained about health in the East Harlem population.16 All the findings of the survey were reviewed with the community and a special monograph was published and shared so that local organizations could use the same sophisticated data base for their grant applications to government or foundations. 17 Another priority was to define the operational policy that the department would adopt regarding improvement in the provision of health care in the area. The operational policy which was finally established was borrowed from the model of the land-grant agricultural universities. This highly successful model probably has been responsible for the worldwide preeminence of United States agriculture. The land-grant universities have moved the scientific base of agricultural technology and practice from the academic halls to the experimental farms, where innovations are adapted to local and regional conditions.18 Effective methods and technologies emanating from the model projects are channeled through agricultural extension agents, who, in turn, educate and train the farmers-the practitioners-through practical instruction in improved methods of farming. The system of applying academic agriculture to the field has become an effective, orderly partnership. The university does what it can do best-teaching and research. The service activities involve providing technical assistance and the model-building and evaluation capabilities that the university uniquely can generate. SERVICE GOALS AND OBJECTIVES Inspired by the example of the land-grant system, the Department of Community Medicine decided to apply some of these lessons. The department made the necessary adaptations to the medical-school setting, especially in relation to the contributions that the school could make toward a more effective organization of health-care services in East Harlem. With this policy as a basis, the service goals and objectives of the department were agreed upon. Indeed, the key to the practice of community medicine is clear definition of the service role. Vol. 53, No. 5, June 1977
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The over-all goal in East Harlem is to contribute to the improvement of health-care services in the area without assuming direct responsibility for the administration or actual provision of health-care services while taking into consideration the pluralistic nature of our society. The building of models and demonstration projects does not assure continuous, long-term service responsibility. The goal of the department is to participate with a broad variety of community groups (consumers and providers of care) in a continuing process of identifying and solving problems related to the organization and provision of health care. Therefore, the major secondary goals are: to encourage a more rational use of existing resources in the area; to foster interorganizational linkages, mergers, and agreements; and, ultimately, to attain a logical regionalization of health services in the area. The five basic service objectives that define the practice of community medicine in our department are these: 1) To assist community groups (providers and consumers of care) in the translation of recognized health needs into the formulation of specific problems to be solved 2) To participate with the community groups in the identification of possible alternative solutions to their problems, and to review and reset the priorities of alternative solutions in terms of their feasibility 3) To aid the community groups in developing goals and objectives for their programs and in converting them into programs of action 4) To assist hospitals and other providers of health care in the region in defining their roles in relation to the needs of consumers and to cooperate with them in the development of new organizational models 5) To communicate the experiences and results which our department has derived from the implementation of the above-mentioned aims among the different groups of consumers and providers in the region, and to contribute to an effective coordination of their resources and efforts. PROGRAM DEVELOPMENT
Since its establishment in 1968 the department has made significant advances in the fulfillment of these goals and objectives, in the definition of its role as a multidisciplinary agency available to provide technical assistance to the community, and in the characterization of the tasks entailed in this form of community medical practice. The department has participated and increasingly participates with a broad variety of comBull. N.Y. Acad. Med.
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munity groups in East Harlem, providing them with technical assistance in the design, planning, organization, development, and evaluation of a wide range of service activities and programs. The groups to which it provides these services belong either to the public or the private sectors. In keeping with its participatory approach, the department is paid for most of the services it provides. To explicate the department's role, the diversity of its functions, and the tasks entailed in the development of health-care programs, we shall present selected examples of programs in summary form to illustrate the type of responsibilities the department has undertaken and to present some of the results already attained in East Harlem. Some of these programs already have been described and analyzed elsewhere in greater detail. 19-45 At the request of the Department of Health of the City of New York and in collaboration with the Model Cities program, our department engaged in the planning and development of a demonstration project that transformed a New York City well-baby clinic (the Wagner Health Station) into a model child-care program controlled by nurse-practitioners and offering primary care as well as outreach preventive services in a geographically defined area. The project opened August 1, 1971 as a demonstration of how a small neighborhood health team in a child-health station could provide family-oriented primary pediatric care at a reasonable cost to a defined group of children. An estimated total population of 1,800 preschool children lived in Health Area No. 17, where the program was located. In two years registration grew from about 800 children in the clinic before the start of the project to approximately 1,350 children. On July 11, 1975 the administration of this program was taken over successfully by a community organization; the program became the nucleus of an East Harlem community-governed neighborhood health center for total care of families in the area. Basic components of the model-such as health teams led by public health nurse-practitioners, medical care protocols, and outreach activities-have been maintained and expanded by the new administration. At the request of the East Harlem Tenants Council (EHTC), a Puerto Rican community organization, the department participated in the discussion of possible alternative solutions to the problem of providing total health care for East Harlem. These discussions led the EHTC to decide to erect and assume responsibility for governing a neighborhood health center. With the cooperation of our department, the program was designed Vol. 53, No. 5, June 1977
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so that it eventually could be converted into the medical group of a health maintenance organization (HMO) in the area. Under project grant No. 02-H-000, 386-01 from the U.S. Department of Health, Education, and Welfare (HEW), the EHTC took over the above-mentioned child-health station demonstration project. It now offers comprehensive primary health care and related services to families of a specific population from East Harlem; it is linked to the Hospital for Joint Diseases (a voluntary hospital located in the northern part of East Harlem) and the Mount Sinai Hospital and provides specialty and subspecialty ambulatory and inpatient care for persons registered at the center. The projected goal when it reaches full operation is to serve 24,000 to 30,000 registered patients. The projected ultimate location of the program is the Taino Towers, a low-income residential and human-services complex at Third Avenue and 123rd Street. The EHTC continues to subcontract for technical assistance from our department in the continuing evaluation of its activities. At the request of the Hospital for Joint Diseases, our department is involved with the staff of that hospital in the processes of reexamining the goals and objectives of the institution as it moves toward a new identity as a community hospital. Since the hospital is affiliated with the Mount Sinai Hospital, the department is an active consultant in the process of redefining the role of this hospital within the evolving health-care delivery system of this community. At the request of the Mount Sinai Hospital itself, the Department of Community Medicine has functioned and continues to function as a research and technical-assistance unit for the improvement of ambulatorycare services in the hospital. A team of three social scientists is continuously engaged in a program of concurrent evaluation, a type of action or policy research designed to study the delivery of health care and to provide a regular flow of information for modifying patient services. The field of study covers interpersonal and interorganizational relations among staff and between staff and patients that affect the care of patients. Specific topics of study up to now have been: unmet demands of patients, improvement of services, the effect of cultural differences between consumers and providers on compliance with health-care procedures, the effect of an appointment system on continuity of care, and responses by consumers to a joint provider-consumer poll of satisfactions and dissatisfactions with the outpatient services. At the request of the Yorkville Medical Group of the Health Insurance Bull. N.Y. Acad. Med.
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Plan of Greater New York (HIP), one of the 28 medical groups which provides services to members enrolled in HIP, our department functioned as consultant in the development of an adolescent-care program in their East Harlem center. We also cooperated in the introduction in that center of the Weed problem-oriented record and the Williamson method of continuing education and quality control. The department also has participated in the development of an improved data-collection system, a drugcounseling program, a program in sex education, and a program in nutritional education. The Yorkville Medical Group assumes responsibility for the medical care of a population of some 25,000 residents of the East Harlem and Yorkville areas of Manhattan. Needed services are provided in two locations, one in Yorkville and the other in East Harlem. A later request from the same medical group was for assistance in the development of expertise in the administration of medical care among the East Harlem practitioners. This task has been performed through special on-the-job training programs and continuing consultation. At the request of the New York State Department of Social Services, together with the New York City Board of Education and the New York City Department of Health, our department is now involved in a complex planning and system-building effort. Based on findings in the East Harlem school-health system, an interinstitutional venture now is under way to build and implement a prepaid model of care that will expand access and improve health-care services to children and their families in the area. The purpose of this demonstration project is to develop and test an organized administrative structure capable of assuming responsibility for financing health care and monitoring the organization and quality of services. The structure will be capable of establishing and maintaining viable linkages between the local agencies responsible for school health and existing local providers of care. The major focus of the project is the improvement of access through new methods of marketing health care to urban-core families. The initial target population of the demonstration has been limited deliberately to 2,000 persons comprising children who attend four East Harlem schools, their siblings, and their parents. Inspired by the marketing-through-employment methods of the Kaiser Permanente system, the project will consider the child in school as the "employed family member" and the school as "the place of employment." Enrollment will be offered to the children and their families through the schools with the cooperation of the school administration. The actual provision of the professional health services will be the responsibility of existing local Vol. 53, No. 5, June 1977
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health-care providers who will enter into a capitation contractual agreement within the administrative structure. If and when the system is viable, it is designed to become an independent, regional, community-governed agency. At the request of District 1199, the National Union of Hospital and Health Care Employees, AFL-CIO, sponsor of an urban renewal housing project on First Avenue between 107th and 111th Streets, our department has functioned as a consultant in a study of the feasibility of HMOs. The union wanted to develop a prepaid health-care program within the housing project to serve a variety of consumer groups who live in that building or nearby. The study, completed in the spring of 1973, showed that the population of East Harlem did not have enough purchasing power to maintain an independent prepaid group practice located in that facility. The potential enrollment would be too low for financial self-sufficiency, even if District 1199 joined efforts with HIP or Blue Cross of Greater New York or both. An agreement recently has been signed between District 1199 and the Yorkville medical group of HIP to open a small satellite center in the housing project. At the request of Union Settlement, our department has participated in the planning of a community pharmacy designed to provide both pharmaceutical and primary health-care services to the population of the Metropolitan-North area of East Harlem. When the program is operational it will be governed by Union Settlement.
COMMENT AND CONCLUSIONS During the first years of our departmental development there were times when we almost capitulated to requests of the local residents and neighborhood organizations to provide medical center "missionary" care-direct, long-term commitments for health services to the underserved neighborhood. It seemed as if the application of the agricultural model, so attractive in theory, would never have the chance to be tested. Nevertheless, during that initial stage we began by getting to know the community, building trust with community leaders and organizations, and using the experience garnered from the study of the community's health problems to disseminate knowledge both in the community and within the medical center. Now that eight years have elapsed, we can say with confidence that we have progressed to the stage of active involvement in the solution of problems in partnership with East Harlem groups and that Bull. N.Y. Acad. Med.
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we are in the midst of what is possibly an irreversible process of change. The community is aware of the data that are available in the department and its value as a basic resource for the planning, development, and evaluation of health services. At this stage of awareness, communications between the community and the medical center have become very important for the diffusion of ideas of change. We are consulted frequently and continue to provide information about East Harlem (from the census and from the department survey), thereby helping to locate target populations in the area in order to provide a more precise definition of need, to reflect opinions expressed by a cross-section of residents, or to provide the baseline for evaluation or for writing proposals. The multiplicity and nature of the requests that we receive from groups of consumers and providers (some from outside East Harlem) have obliged us to establish the clearest possible priority guidelines for response. The choice of response usually is dictated by the relevance of the request to problems identified by the community studies and data that already exist. For example, we know that there are sufficient hospital resources, but that there are deficiencies in certain types of programs - especially in community outreach and primary care. We have identified scarcities and poor patterns of distribution. One case of response to this problem has been the development of the nurse-practitioner primary-care model in the New York City Child Health Station. In a pluralistic society such as ours, we believe that a community-based opportunity for regionalized personal health services should have top priority. Therefore, we saw a large opportunity in the EHTC's request for help in planning and developing a neighborhood health center. We believed that a new primary-care center could be linked to the Hospital for Joint Diseases as a secondary-care hospital, with the Mount Sinai Hospital as the tertiary-care hospital. In a community in which there is little appropriate health insurance through employment it is important to test alternative frameworks for reaching the population and providing organized access to a system of care. A key problem involves opening multiple options and the marketing of prepaid health systems. One response to this problem is the pilot program of the prepaid system project that will link school health with providers of medical care. It was an early policy decision of our department to work with a large, existing system of prepaid health care such as HIP. A strong relation has Vol. 53, No. 5, June 1977
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been forged between the Mount Sinai Hospital and HIP. We regard HIP as a particularly rich source of information about various approaches to health-care delivery, especially because HIP itself contains diverse organizational arrangements. It is this close working relation that has enabled us to assist in the organization of their adolescent program. Once a decision has been reached in our department to collaborate with a group of providers or consumers, we formalize the involvement of the department in a preliminary cooperative effort. For example, in July 1974 EHTC approached the department requesting technical assistance for the development of its neighborhood health center program. A formal decision was made to provide this assistance and an agreement was signed between the two institutions. Departmental manpower and space were allocated to this effort and assistance was provided in the preparation of a grant proposal that was later funded by HEW. Once a project has its funding assured and the planning and implementation phases of a program become feasible, staff members from different disciplines within our department are assigned to work as needed with the group for long or short periods on a part-time schedule. Formal agreements are reached that include reimbursement to the department for consultative services. For example, the director of the services unit in the department and one Hispanic planner meet regularly with policy makers and the director of EHTC and are active in the operational stages and special programs of the family health center. After a health program is operational and the system is receptive to change, the primary role of the services unit is evaluation. The Mount Sinai Hospital itself, which we consider to be a provider group in the community, recognized the need for change and requested assistance in the reorganization of some aspects of ambulatory care. Appropriate funding was allocated by the hospital, and the team of three sociologists is involved continuously in the program that provides information for action in the planned change of services for patients. From what we have seen in medical centers in the United States and in other countries, the practice of community medicine usually is not an integral part of a medical school-hospital complex. Under such circumstances the influence of the community health sciences on the provision of health-care services is seriously attenuated. At this point in the history of the Mount Sinai School of Medicine, a growing number of opportunities for cooperation with our clinical colleagues in the hospital and in the Bull. N.Y. Acad. Med.
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school are taking place. A variety of joint programs are in progress with the departments of medicine, pediatrics, obstetrics, surgery, psychiatry, and dentistry built around issues of health-care delivery and categorical problem areas such as early detection of impairments and diseases. Without the integrated daily interaction of clinical sciences, basic sciences, and community medicine, we doubt that so many and such diverse opportunities for joint actions would have evolved. Sitting on medical school and hospital committees on an equal basis has increased the rapport and understanding by members of the three faculties of what each can contribute to the improvement of health services in the hospital and in the community. The foundation for the coordination of health services with educational activities now exists in a meaningful manner. If we expect to produce physicians who are skilled in identifying and solving health problems in groups as well as in individual patients, we must insist that education and training in community medicine be a necessary prerequisite for the M.D. degree. Inherent in what has been described as community medical practice lies the substance on which our educational method of learningby-doing thrives. Without active involvement in a problem-solving approach to the actual world of health-care delivery, capturing the interest and attention of medical students has proved difficult. At the Mount Sinai Hospital all medical students rotate during the third year through fourweek clerkships in community medicine.46 With appropriate tutorial guidance they become useful members of our technical assistance teams and ideal partners in the continuous process of change in which we are involved with the community clientele.47 When our enrollments reach the maximum of 120 students we shall provide an annual technical input equivalent to nine full-time persons. With many students taking elective work throughout the four-year undergraduate curriculum and a minimum of five residents in community medicine, there is a social health practice and research contribution to our many client communities equivalent to the input of 15 persons per year. This represents an enormous student contribution of service which, in addition to its inherent educational and didactic value, has already had a significant effect on the provision of health care in our institutions and the contiguous communities. There are 48 university medical centers in the United States serving in metropolitan areas of greater than one million population. If each center contributed its fair share of technical assistance and built models to help Vol. 53, No. 5, June 1977
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solve its regional urban health problems, society would reap immeasurable benefits and, we believe, would respond with strong support of university medical centers. The time has come for the policy-makers in academic centers to acknowledge the changing role of universities and to mobilize their resources for society. To evade this issue is to have society impose its pattern of change on the academic structure. Nowhere is this clearer than in the rough-and-tumble big city environment. What has been said from the perspective of eight years of experience with community medical practice at the Mount Sinai Hospital may not apply to the total spectrum of national urban health issues. However, we are confident that many aspects of the problem-solving model developed in New York City at the Mount Sinai Hospital in the organization of health-care delivery apply to the nation. Some of the lessons we have learned in these areas also can be applied usefully in the United States in areas well beyond the big cities and in other countries as well.
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REFERENCES Deuschle, K. W.: Urban Health and 7. Santas, A.: II Conferencia de EducaAcademic Medicine (Changing Reci6n MWdica. Federacion Pansponsibilities of Medical Schools in americana de Asociaciones de FaculBig Cities). The Merrimon Lecture, tades de Medicina, Buenos Aires, University of North Carolina School of November 4-6, 1970. Medicine, Chapel Hill, N.C., October 8. English, J. T.: The changing scene. II. 15, 1975. J. Med. Educ. 45:968, 1970. Candau, M. G.: Inaugural Session 9. Cooper, J.: The academic medical center in the years ahead. J. Med. Address. Third World Conference on Medical Education. New Delhi, India, Educ. 47:39, 1972. 10. Ebert, R. H.: The medical school. Sci. November 20, 1966. Am. 229:139, 1973. Gardner, J. W.: The worlds of reflec11. Navarro, V.: Let's change our ways of tion and action. Science 159:849, 1966. improving health. Johns Hopkins Mag. 25:5, 1974. Sanazaro, P. J.: Innovations in medical 12. Somers, A. R.: University hospital: education: Social scientific determiFuture role. Hospitals 45:41, 1971. nants. Arch. Neurol. 17:484, 1967. 13. Haggerty, R. J.: The university and Popper, H. and Koffler, D.: The goal. primary medical care. N. Engl. J. J. Mt. Sinai Hosp. 34:366, 1967. Med. 8:281, 1969. Velazquez, G.: Conceptos y objetivos 14. Evans, R. L., Pittman, J. G., and de la educacion en las ciencias de la Peters, R. C.: The community-based salud. II Conferencia de Educaci6n medical school. Reactions at the interMgdiGa, Federacion Panamericana de face between medical education and Asociaciones de Facultades de medical care. N. Engl. J. Med. 288: Medicina. Mexico City, September 713, 1973. 24-26, 1969. Bull. N.Y. Acad. Med.
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15. Community Medicine at Mount Sinai School of Medicine. The Mount Sinai School of Medicine of the City University of New York. New York, January 1975. Unpublished. 16. Johnson, L., Lynch, A., and Rivera, O.: East Harlem community study. The Mount Sinai School of Medicine of the City University of New York. New York, May 1972. Unpublished. 17. Johnson, L., editor: The People of East Harlem. New York, Dept. Community Medicine, The Mount Sinai School of Medicine of the City University of New York, 1975. 18. Lind, G.: Statistics of Land Grant Colleges and Universities, 1963. U.S. Dept. HEW OE-50002-63. Circular No. 763. Washington, D.C., Supt. of Documents, 1960. 19. Deuschle, K. W., Goodrich, C. H., and Olendzki, M.: Mount Sinai's approach to the East Harlem community. Bull. N.Y. Acad. Med. 46:97, 1970. 20. Moss, J. Z.: Concurrent evaluation: An approach to action research. Soc. Sci. Med. (suppl.) 4:25, 1970. 21. Berkman, B., Rehr, H., Siegel, D., et al.: Utilization of inpatient services by the elderly. J. Am. Geriatr. Soc. 19: 933, 1971. 22. Wood, C., Volante, R., and Berenson, R.: An epidemiologic study of amputees in the East Harlem community. Health Serv. Rep. 86:1092, 1971. 23. Deuschle, K. W.: On defining community medicine service. Ann. N. Y. Acad. Sci. 196:158, 1972. 24. Rehr, H.: Mount Sinai's social services in East Harlem. Ann. N.Y. Acad. Sci. 196:80, 1972. 25. Christakis, G.: The community nutrition team. Ann. N.Y. Acad. Sci. 196: 78, 1972. 26. McCann, W.: The family health worker. Ann. N.Y. Acad. Sci. 196:68, 1972. 27. Reichman, S. and Machaver, H.: The four-legged stool: Community participation, community medicine, and the community hospital. J. A.M.A. 219: 196, 1972. 28. Hughes, E. F. X.: Transportation for health in the East Harlem triangle.
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Ann. N.Y. Acad. Sci. 196:64, 1972. 29. Olendzki, M., Grann, R. P., and Goodrich, C. H.: The impact of Medicaid on private care for the urban poor. Med. Care 10:201, 1972. 30. Richter, E., Jackson, S., Peeples, S. et al.: Housing and health: A new approach. Am. J. Public Health 63:878, 1973. 31. Safir, A., Kulikowski, C., and Deuschle, K. W.: Automatic refraction: How it is done: Some clinical results. Sight Sav. Rev. 43:137, 1973. 32. Safir, A., Kulikowski, C., Crocetti, A. F. et al.: A new method of vision care delivery. Health Serv. Rep. 88: 405, 1973. 33. Belville, R., Myerson, A. T., Moss, J. Z. et al.: The elderly patient in a psychiatric acute care clinic of a general hospital. American Gerontology Association, Miami, November 4, 1973. 34. Frankle, R. and Christakis, G.: The hospital-the community: Nutrition services can provide the link. Hospitals 47:56, 1973. 35. Bosch, S. J., Banta, H. D., Watkins, R. et al.: The Mount Sinai-HIP joint program: A manpower training program in an HMO. Health Serv. Rep. 89:219, 1974. 36. Johnson, L. A.: Use of alcohol by persons sixty-five years and over, upper east side of Manhattan. The Mount Sinai School of Medicine of the City University of New York, New York, 1974. Unpublished. 37. Marshall, C. L. and Lewis, A. M.: The student health opportunities program at the Mount Sinai School of Medicine. Health Serv. Rep. 89:152, 1974. 38. Wood, C., Volante, R., Peeples, S. et al.: An experiment to reverse healthrelated problems in slum housing maintenance. Am. J. Public Health. 64:474, 1974. 39. Brown, R. and Rawls, W. B.: School health services for the future. N.Y. State J. Med. 75:616, 1975. 40. Thomstad, B., Cunningham, N., and Kaplan, B. H.: Changing the rules of the doctor-nurse game. Nurs. Outlook
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23:422, 1975. 41. Cunningham, N., Murphy, R., Belville, R. et al.: PCPs for the PNA: The development and use of primary care protocols (standing orders) for pediatric nurse associates. Proc. Soc. for Advanced Med. Systems. Symposia Specialists, Miami, Fla., 1975, p. 135. 42. Cunningham, N.: The MCH Primary Health Worker, Rural and Urban. In: Health in Community Development, Perpick, J. G., editor. Washington, D.C., Nat. Acad. Sci., 1975, p. 159. 43. Wallerstein, E., Marshall, C. L., Alexander, R. et al.: Pediatric outreach via television. Nurs. Digest 2: 74, 1974. 44. Marshall, C., Wallerstein, E., Alex-
ander, R. et al.: Television for the elderly: A new approach to health. Educ. Ind. Telev. 7:28, 1975. 45. Cunningham, N. and Thacker, S. B.: Health accounting at the Wagner Child Health Station: A practical attempt at quality care assessment. Clin. Pediatr. 15:811, 1976. 46. Deuschle, K. W., Bosch, S. J., Banta, H. D. et al.: The community medicine clerkship: A learner-centered program. J. Med. Educ. 47:931, 1972. 47. Bentkover, S. H., Bernstein, R., Greenberg, A. et al.: Student perspectives on learning in a prepaid group practice. Health Serv. Rep. 89:225, 1974.
Bull. N.Y. Acad. Med.
THE ROLE OF A MEDICAL SCHOOL IN THE ORGANIZATION OF HEALTH-CARE SERVICES* SAMUEL J. BOSCH, M.D. Associate Professor and Deputy Chairman
KURT W. DEUSCHLE, M.D. Ethel Wise Professor of Community Medicine and Chairman Department of Community Medicine The Mount Sinai School of Medicine of the City University of New York New York, N.Y.
IN A VARIETY of ways society is demanding participation from the I medical schools in the solution of pressing problems of national and community health. The United States Congress and state and municipal governments, joined by social health agencies and organizations, are forcing more community-health-directed goals on academic medical centers. They are goading medical schools into action, commitment, and leadership by rewarding compliant institutions with federal, state, and municipal funds. ' The medical schools themselves are increasingly recognizing that they have some responsibility to respond to these pressures, particularly as they relate to changes required in manpower and the organization of the healthcare system. To judge by the increasing frequency with which publications on those matters have been appearing, the subject undoubtedly is of more than temporary interest. Outstanding medical statesmen throughout the world have appealed repeatedly to the academic leadership in medicine to accept a more active role in social health.
APPEALS FOR A CHANGE IN SOCIAL ROLE
Marcelino Candau, as general director of the World Health Organization, reviewed in 1966, at the Third World Conference on Medical Education, the effects that social change and scientific advances would have upon the social obligations of medicine.2 In the same year John Gardner *Presented as part of a Symposium on the Medical School and Its Surrounding Community held by the Committee on Medical Education of the New York Academy of Medicine October 14, 1976. Presented in part as the Merrimon Lecture in Medicine at the School of Medicine, University of North Carolina, Chapel Hill, N.C., October 15, 1975.
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called for every great university "to balance its responsibilities to the worlds of reflection and action" and asserted that both "detached scientists and those who will become involved in the world of action are essential to a society that aspires to creativity." 3 P.J. Sanazaro, commenting on the sudden emphasis on quality of care, argued for new responsibilities for direct involvement in the medical care system by the medical centers.4 Hans Popper, as one of the founders of the Mount Sinai School of Medicine in New York, asserted that the major goal of new and old medical schools should be to produce physicians whose training will be consonant with the future needs of society.5 Meanwhile, the same issues were being raised in other countries. In Latin America, Gabriel Velazquez was urging the involvement of academic medical centers in new types of research that would lead to the development of well-organized regional and national health-care systems,6 and the Pan American Federation of Associations of Medical Schools advocated the bringing together of medical schools and the social security health systems.7 More recently, J. T. English, commenting on the many serious inadequacies of our health services, requested that "new organizational models for health care delivery be supported, studied, and compared and that, in order to be sure that the vast talent of the nation's medical schools contributes to these efforts, departments of social and community medicine be supported.' '8 J. Cooper asserted that "the extension of federal involvement in health will focus more attention on every segment of the system, including the priorities and programs of the academic medical centers." He expects an increase in federal pressure-probably through the mechanism of financing-to result in extending the responsibility of the academic medical center for the provision of health care.9 R. H. Ebert stated that "the schools are under pressure to experiment with the medical care system to put more emphasis on ambulatory care and comprehensive care, provide primary care for communities adjacent to teaching hospitals and participate in regional planning."10 According to V. Navarro, "Our medical schools will have to realize that their parochial and mechanistic approach to medicine must be broadened; that they must recognize that the health of our people depends primarily on methods directed at populations rather than at individuals." He asserted that "some changes are in fact occurring, with medical schools now taking direct responsibility for the care of population besides individuals." '11 These appeals have stimulated much debate over where to draw the line for the social responsibility of the academic centers regarding, for examBull. N.Y. Acad. Med.
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ple, such an important issue as the organization and provision of health care.12-14 The enormous social and ecological problems of big cities exaggerate even further the challenge of determining where the academic medical centers can mark their legitimate boundaries of responsibility and accountability in this matter. In New York City, with a population of about eight million people and seven major medical schools, the issue of community commitment is extremely volatile. This issue is especially volatile in a new and evolving urban medical school such as the Mount Sinai School of Medicine of the City University of New York in upper Manhattan. The purpose of this paper is to present and analyze the role and responsibilities that the Department of Community Medicine of the Mount Sinai School of Medicine has assumed with respect to the organization of health-care delivery in East Harlem, its contiguous community.
THE SOCIAL COMMITMENT OF MOUNT SINAI The Mount Sinai School of Medicine of the City University of New York, founded in 1966 and opened in 1968, represents the union of a large voluntary hospital and a public university, each renowned for its longstanding pursuit of excellence. From the outset the founders of the medical school made the identification and solution of community health problems a clear institutional goal. They reasoned that this social commitment would be meaningless if it were not translated into a full-time faculty of community health scientists working side by side on a daily basis with the basic scientists and clinical faculty of the medical center. They therefore established a generously endowed Department of Community Medicine, envisioning it as an essential resource for contemporary medical education, research, and service.'5 Today the Department of Community Medicine is organized as a large, interdisciplinary "third faculty" of the medical school that complements the basic and clinical sciences faculties.* One of the department's principal mandates is to serve as a bridge between the resources of the medical center and those of the surrounding community, East Harlem, in a joint problem-solving effort.
THE SURROUNDING COMMUNITY East Harlem is located in the northeast corner of Manhattan, north of 96th Street and east of Fifth Avenue. During the early 1900s it was the *The approximately 50 full-time and 100 part-time faculty of the department represent the following major disciplines: behavioral science, environmental science, epidemiology, health economics, nursing, medicine, and social work.
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home of Italian and Jewish immigrant workers. Today the demographic picture has changed, and people of Puerto Rican origin make up 45% of the population, blacks another 35%, whites of direct European ancestry 17%, and "others" 3%. 16 The area, always inhabited by relatively low income groups, has deteriorated into the kind of ghetto area for which New York is infamous. Many of the households have no income from employment, and most of those who work hold low-paying jobs. Social problems and a high level of morbidity characterizes the population. In 1968 the East Harlem community was in a high fever of frustration and anger over the many inequities that plague the inner cities. There were angry confrontations over health-care services. Community demands transcended what the establishment considered legitimate medical-care concerns. Health-related issues in employment, housing, education, transportation, and security became entangled with the more medically oriented issues of the hospital and the clinic. There was antagonism between blacks and Puerto Ricans for political power and leadership roles with regard to the various community issues, including health. However, many community organizations were working to improve conditions, and there is evidence that their efforts have been and will continue to be productive. Our 1970 survey shows that the different ethnic groups within East Harlem have identified a common set of problems and have set priorities for dealing with them. 16 STRATEGIES AND POLICY One priority of the Department of Community Medicine was to learn how the Mount Sinai medical center could assist in improving health in East Harlem. The initial strategy was to establish a solid base of information about health in the community and to make existing community groups (consumers and providers of care) aware that a new resource for health was becoming available in the area. It soon became apparent that we could not simply wait for these groups to come to us with problems. An early Department of Health, Education, and Welfare grant enabled us to cooperate with the East Harlem Health Council (EHHC), a communitywide health group that included both consumers and providers of health care in the area. It was agreed that we needed an unbiased assessment of the health situation, as opposed to a possible potpourri of health demands based on priorities stemming from special-interest groups. Our decision to undertake a household survey proved to be a significant Bull. N.Y. Acad. Med.
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step in our relation with the community. All plans for the survey were reviewed with representatives of the community through the EHHC. Questionnaires were written in Spanish as well as English, and each question was pretested for the effectiveness of the communication. Then a 2% straight probability sample of households was selected; a survey of 78% of the sample was completed. Because our survey was carried out in 1970, our data could be compared with information derived from the United States census. Valuable insights were gained about health in the East Harlem population.16 All the findings of the survey were reviewed with the community and a special monograph was published and shared so that local organizations could use the same sophisticated data base for their grant applications to government or foundations. 17 Another priority was to define the operational policy that the department would adopt regarding improvement in the provision of health care in the area. The operational policy which was finally established was borrowed from the model of the land-grant agricultural universities. This highly successful model probably has been responsible for the worldwide preeminence of United States agriculture. The land-grant universities have moved the scientific base of agricultural technology and practice from the academic halls to the experimental farms, where innovations are adapted to local and regional conditions.18 Effective methods and technologies emanating from the model projects are channeled through agricultural extension agents, who, in turn, educate and train the farmers-the practitioners-through practical instruction in improved methods of farming. The system of applying academic agriculture to the field has become an effective, orderly partnership. The university does what it can do best-teaching and research. The service activities involve providing technical assistance and the model-building and evaluation capabilities that the university uniquely can generate. SERVICE GOALS AND OBJECTIVES Inspired by the example of the land-grant system, the Department of Community Medicine decided to apply some of these lessons. The department made the necessary adaptations to the medical-school setting, especially in relation to the contributions that the school could make toward a more effective organization of health-care services in East Harlem. With this policy as a basis, the service goals and objectives of the department were agreed upon. Indeed, the key to the practice of community medicine is clear definition of the service role. Vol. 53, No. 5, June 1977
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The over-all goal in East Harlem is to contribute to the improvement of health-care services in the area without assuming direct responsibility for the administration or actual provision of health-care services while taking into consideration the pluralistic nature of our society. The building of models and demonstration projects does not assure continuous, long-term service responsibility. The goal of the department is to participate with a broad variety of community groups (consumers and providers of care) in a continuing process of identifying and solving problems related to the organization and provision of health care. Therefore, the major secondary goals are: to encourage a more rational use of existing resources in the area; to foster interorganizational linkages, mergers, and agreements; and, ultimately, to attain a logical regionalization of health services in the area. The five basic service objectives that define the practice of community medicine in our department are these: 1) To assist community groups (providers and consumers of care) in the translation of recognized health needs into the formulation of specific problems to be solved 2) To participate with the community groups in the identification of possible alternative solutions to their problems, and to review and reset the priorities of alternative solutions in terms of their feasibility 3) To aid the community groups in developing goals and objectives for their programs and in converting them into programs of action 4) To assist hospitals and other providers of health care in the region in defining their roles in relation to the needs of consumers and to cooperate with them in the development of new organizational models 5) To communicate the experiences and results which our department has derived from the implementation of the above-mentioned aims among the different groups of consumers and providers in the region, and to contribute to an effective coordination of their resources and efforts. PROGRAM DEVELOPMENT
Since its establishment in 1968 the department has made significant advances in the fulfillment of these goals and objectives, in the definition of its role as a multidisciplinary agency available to provide technical assistance to the community, and in the characterization of the tasks entailed in this form of community medical practice. The department has participated and increasingly participates with a broad variety of comBull. N.Y. Acad. Med.
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munity groups in East Harlem, providing them with technical assistance in the design, planning, organization, development, and evaluation of a wide range of service activities and programs. The groups to which it provides these services belong either to the public or the private sectors. In keeping with its participatory approach, the department is paid for most of the services it provides. To explicate the department's role, the diversity of its functions, and the tasks entailed in the development of health-care programs, we shall present selected examples of programs in summary form to illustrate the type of responsibilities the department has undertaken and to present some of the results already attained in East Harlem. Some of these programs already have been described and analyzed elsewhere in greater detail. 19-45 At the request of the Department of Health of the City of New York and in collaboration with the Model Cities program, our department engaged in the planning and development of a demonstration project that transformed a New York City well-baby clinic (the Wagner Health Station) into a model child-care program controlled by nurse-practitioners and offering primary care as well as outreach preventive services in a geographically defined area. The project opened August 1, 1971 as a demonstration of how a small neighborhood health team in a child-health station could provide family-oriented primary pediatric care at a reasonable cost to a defined group of children. An estimated total population of 1,800 preschool children lived in Health Area No. 17, where the program was located. In two years registration grew from about 800 children in the clinic before the start of the project to approximately 1,350 children. On July 11, 1975 the administration of this program was taken over successfully by a community organization; the program became the nucleus of an East Harlem community-governed neighborhood health center for total care of families in the area. Basic components of the model-such as health teams led by public health nurse-practitioners, medical care protocols, and outreach activities-have been maintained and expanded by the new administration. At the request of the East Harlem Tenants Council (EHTC), a Puerto Rican community organization, the department participated in the discussion of possible alternative solutions to the problem of providing total health care for East Harlem. These discussions led the EHTC to decide to erect and assume responsibility for governing a neighborhood health center. With the cooperation of our department, the program was designed Vol. 53, No. 5, June 1977
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so that it eventually could be converted into the medical group of a health maintenance organization (HMO) in the area. Under project grant No. 02-H-000, 386-01 from the U.S. Department of Health, Education, and Welfare (HEW), the EHTC took over the above-mentioned child-health station demonstration project. It now offers comprehensive primary health care and related services to families of a specific population from East Harlem; it is linked to the Hospital for Joint Diseases (a voluntary hospital located in the northern part of East Harlem) and the Mount Sinai Hospital and provides specialty and subspecialty ambulatory and inpatient care for persons registered at the center. The projected goal when it reaches full operation is to serve 24,000 to 30,000 registered patients. The projected ultimate location of the program is the Taino Towers, a low-income residential and human-services complex at Third Avenue and 123rd Street. The EHTC continues to subcontract for technical assistance from our department in the continuing evaluation of its activities. At the request of the Hospital for Joint Diseases, our department is involved with the staff of that hospital in the processes of reexamining the goals and objectives of the institution as it moves toward a new identity as a community hospital. Since the hospital is affiliated with the Mount Sinai Hospital, the department is an active consultant in the process of redefining the role of this hospital within the evolving health-care delivery system of this community. At the request of the Mount Sinai Hospital itself, the Department of Community Medicine has functioned and continues to function as a research and technical-assistance unit for the improvement of ambulatorycare services in the hospital. A team of three social scientists is continuously engaged in a program of concurrent evaluation, a type of action or policy research designed to study the delivery of health care and to provide a regular flow of information for modifying patient services. The field of study covers interpersonal and interorganizational relations among staff and between staff and patients that affect the care of patients. Specific topics of study up to now have been: unmet demands of patients, improvement of services, the effect of cultural differences between consumers and providers on compliance with health-care procedures, the effect of an appointment system on continuity of care, and responses by consumers to a joint provider-consumer poll of satisfactions and dissatisfactions with the outpatient services. At the request of the Yorkville Medical Group of the Health Insurance Bull. N.Y. Acad. Med.
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Plan of Greater New York (HIP), one of the 28 medical groups which provides services to members enrolled in HIP, our department functioned as consultant in the development of an adolescent-care program in their East Harlem center. We also cooperated in the introduction in that center of the Weed problem-oriented record and the Williamson method of continuing education and quality control. The department also has participated in the development of an improved data-collection system, a drugcounseling program, a program in sex education, and a program in nutritional education. The Yorkville Medical Group assumes responsibility for the medical care of a population of some 25,000 residents of the East Harlem and Yorkville areas of Manhattan. Needed services are provided in two locations, one in Yorkville and the other in East Harlem. A later request from the same medical group was for assistance in the development of expertise in the administration of medical care among the East Harlem practitioners. This task has been performed through special on-the-job training programs and continuing consultation. At the request of the New York State Department of Social Services, together with the New York City Board of Education and the New York City Department of Health, our department is now involved in a complex planning and system-building effort. Based on findings in the East Harlem school-health system, an interinstitutional venture now is under way to build and implement a prepaid model of care that will expand access and improve health-care services to children and their families in the area. The purpose of this demonstration project is to develop and test an organized administrative structure capable of assuming responsibility for financing health care and monitoring the organization and quality of services. The structure will be capable of establishing and maintaining viable linkages between the local agencies responsible for school health and existing local providers of care. The major focus of the project is the improvement of access through new methods of marketing health care to urban-core families. The initial target population of the demonstration has been limited deliberately to 2,000 persons comprising children who attend four East Harlem schools, their siblings, and their parents. Inspired by the marketing-through-employment methods of the Kaiser Permanente system, the project will consider the child in school as the "employed family member" and the school as "the place of employment." Enrollment will be offered to the children and their families through the schools with the cooperation of the school administration. The actual provision of the professional health services will be the responsibility of existing local Vol. 53, No. 5, June 1977
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health-care providers who will enter into a capitation contractual agreement within the administrative structure. If and when the system is viable, it is designed to become an independent, regional, community-governed agency. At the request of District 1199, the National Union of Hospital and Health Care Employees, AFL-CIO, sponsor of an urban renewal housing project on First Avenue between 107th and 111th Streets, our department has functioned as a consultant in a study of the feasibility of HMOs. The union wanted to develop a prepaid health-care program within the housing project to serve a variety of consumer groups who live in that building or nearby. The study, completed in the spring of 1973, showed that the population of East Harlem did not have enough purchasing power to maintain an independent prepaid group practice located in that facility. The potential enrollment would be too low for financial self-sufficiency, even if District 1199 joined efforts with HIP or Blue Cross of Greater New York or both. An agreement recently has been signed between District 1199 and the Yorkville medical group of HIP to open a small satellite center in the housing project. At the request of Union Settlement, our department has participated in the planning of a community pharmacy designed to provide both pharmaceutical and primary health-care services to the population of the Metropolitan-North area of East Harlem. When the program is operational it will be governed by Union Settlement.
COMMENT AND CONCLUSIONS During the first years of our departmental development there were times when we almost capitulated to requests of the local residents and neighborhood organizations to provide medical center "missionary" care-direct, long-term commitments for health services to the underserved neighborhood. It seemed as if the application of the agricultural model, so attractive in theory, would never have the chance to be tested. Nevertheless, during that initial stage we began by getting to know the community, building trust with community leaders and organizations, and using the experience garnered from the study of the community's health problems to disseminate knowledge both in the community and within the medical center. Now that eight years have elapsed, we can say with confidence that we have progressed to the stage of active involvement in the solution of problems in partnership with East Harlem groups and that Bull. N.Y. Acad. Med.
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we are in the midst of what is possibly an irreversible process of change. The community is aware of the data that are available in the department and its value as a basic resource for the planning, development, and evaluation of health services. At this stage of awareness, communications between the community and the medical center have become very important for the diffusion of ideas of change. We are consulted frequently and continue to provide information about East Harlem (from the census and from the department survey), thereby helping to locate target populations in the area in order to provide a more precise definition of need, to reflect opinions expressed by a cross-section of residents, or to provide the baseline for evaluation or for writing proposals. The multiplicity and nature of the requests that we receive from groups of consumers and providers (some from outside East Harlem) have obliged us to establish the clearest possible priority guidelines for response. The choice of response usually is dictated by the relevance of the request to problems identified by the community studies and data that already exist. For example, we know that there are sufficient hospital resources, but that there are deficiencies in certain types of programs - especially in community outreach and primary care. We have identified scarcities and poor patterns of distribution. One case of response to this problem has been the development of the nurse-practitioner primary-care model in the New York City Child Health Station. In a pluralistic society such as ours, we believe that a community-based opportunity for regionalized personal health services should have top priority. Therefore, we saw a large opportunity in the EHTC's request for help in planning and developing a neighborhood health center. We believed that a new primary-care center could be linked to the Hospital for Joint Diseases as a secondary-care hospital, with the Mount Sinai Hospital as the tertiary-care hospital. In a community in which there is little appropriate health insurance through employment it is important to test alternative frameworks for reaching the population and providing organized access to a system of care. A key problem involves opening multiple options and the marketing of prepaid health systems. One response to this problem is the pilot program of the prepaid system project that will link school health with providers of medical care. It was an early policy decision of our department to work with a large, existing system of prepaid health care such as HIP. A strong relation has Vol. 53, No. 5, June 1977
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been forged between the Mount Sinai Hospital and HIP. We regard HIP as a particularly rich source of information about various approaches to health-care delivery, especially because HIP itself contains diverse organizational arrangements. It is this close working relation that has enabled us to assist in the organization of their adolescent program. Once a decision has been reached in our department to collaborate with a group of providers or consumers, we formalize the involvement of the department in a preliminary cooperative effort. For example, in July 1974 EHTC approached the department requesting technical assistance for the development of its neighborhood health center program. A formal decision was made to provide this assistance and an agreement was signed between the two institutions. Departmental manpower and space were allocated to this effort and assistance was provided in the preparation of a grant proposal that was later funded by HEW. Once a project has its funding assured and the planning and implementation phases of a program become feasible, staff members from different disciplines within our department are assigned to work as needed with the group for long or short periods on a part-time schedule. Formal agreements are reached that include reimbursement to the department for consultative services. For example, the director of the services unit in the department and one Hispanic planner meet regularly with policy makers and the director of EHTC and are active in the operational stages and special programs of the family health center. After a health program is operational and the system is receptive to change, the primary role of the services unit is evaluation. The Mount Sinai Hospital itself, which we consider to be a provider group in the community, recognized the need for change and requested assistance in the reorganization of some aspects of ambulatory care. Appropriate funding was allocated by the hospital, and the team of three sociologists is involved continuously in the program that provides information for action in the planned change of services for patients. From what we have seen in medical centers in the United States and in other countries, the practice of community medicine usually is not an integral part of a medical school-hospital complex. Under such circumstances the influence of the community health sciences on the provision of health-care services is seriously attenuated. At this point in the history of the Mount Sinai School of Medicine, a growing number of opportunities for cooperation with our clinical colleagues in the hospital and in the Bull. N.Y. Acad. Med.
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school are taking place. A variety of joint programs are in progress with the departments of medicine, pediatrics, obstetrics, surgery, psychiatry, and dentistry built around issues of health-care delivery and categorical problem areas such as early detection of impairments and diseases. Without the integrated daily interaction of clinical sciences, basic sciences, and community medicine, we doubt that so many and such diverse opportunities for joint actions would have evolved. Sitting on medical school and hospital committees on an equal basis has increased the rapport and understanding by members of the three faculties of what each can contribute to the improvement of health services in the hospital and in the community. The foundation for the coordination of health services with educational activities now exists in a meaningful manner. If we expect to produce physicians who are skilled in identifying and solving health problems in groups as well as in individual patients, we must insist that education and training in community medicine be a necessary prerequisite for the M.D. degree. Inherent in what has been described as community medical practice lies the substance on which our educational method of learningby-doing thrives. Without active involvement in a problem-solving approach to the actual world of health-care delivery, capturing the interest and attention of medical students has proved difficult. At the Mount Sinai Hospital all medical students rotate during the third year through fourweek clerkships in community medicine.46 With appropriate tutorial guidance they become useful members of our technical assistance teams and ideal partners in the continuous process of change in which we are involved with the community clientele.47 When our enrollments reach the maximum of 120 students we shall provide an annual technical input equivalent to nine full-time persons. With many students taking elective work throughout the four-year undergraduate curriculum and a minimum of five residents in community medicine, there is a social health practice and research contribution to our many client communities equivalent to the input of 15 persons per year. This represents an enormous student contribution of service which, in addition to its inherent educational and didactic value, has already had a significant effect on the provision of health care in our institutions and the contiguous communities. There are 48 university medical centers in the United States serving in metropolitan areas of greater than one million population. If each center contributed its fair share of technical assistance and built models to help Vol. 53, No. 5, June 1977
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solve its regional urban health problems, society would reap immeasurable benefits and, we believe, would respond with strong support of university medical centers. The time has come for the policy-makers in academic centers to acknowledge the changing role of universities and to mobilize their resources for society. To evade this issue is to have society impose its pattern of change on the academic structure. Nowhere is this clearer than in the rough-and-tumble big city environment. What has been said from the perspective of eight years of experience with community medical practice at the Mount Sinai Hospital may not apply to the total spectrum of national urban health issues. However, we are confident that many aspects of the problem-solving model developed in New York City at the Mount Sinai Hospital in the organization of health-care delivery apply to the nation. Some of the lessons we have learned in these areas also can be applied usefully in the United States in areas well beyond the big cities and in other countries as well.
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