80
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Health Insurance Institute, Washington, D.C.; HON. HAROLD E. FORD, U.S. Congressman (D. Tenn.); PAUL B. CORNELY, M.D., professor emeritus, Department of Community Health Practice, Howard University; MR. ERIC SPRINGER, adjunct professor of hospital law, University of Pittsburgh; MR. DENNIS GOWIE, executive director, Provident Hospital, Balti-
JANUARY, 1976
more, Md., and MR. JEROME ASHFORD, executive director, National Association of Neighborhood Health Centers. The conference was sponsored by the Office of Health Resources Opportunity, Health Resources Administration of the U.S. Department of Health, Education and Welfare.
UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES Public Law 92-426 passed by the 92nd Congress in September 1972 already is being looked upon historically as one of the most important pieces of legislation relative to recruiting and retaining career motivated military medical department personnel for the Armed Forces. The law called for the establishment of a Uniformed Services University of the Health Sciences within 25 miles of the District of Columbia with authority to grant appropriate advanced degrees and to graduate not less than 100 medical students annually with the first class graduating not later than 1982. The second portion of this bill established the Armed Forces Health Professions Scholarship Program for the purpose of obtaining adequate numbers of commissioned officers on active duty qualified in the various health professions. The concept of a military medical school was first introduced in Congress in 1945 and subsequently reintroduced on numerous occasions. The authorizing legislation passed by voice vote in the Senate and in the House of Representatives by a vote of 310-13. Subsequent to the Congressional action, endorsements for the school have been received from civilian academia, organized medicine, the Department of Health, Education and Welfare, and many prestigious scientific organizations. The University will become the unique educational resource of the Department of Defense with the capability of extensive interdisciplinary professional training initially leading to the degree of Doctor of Medicine and as conditions permit, to the appropriate degrees or certification in Dentistry, Nursing, Pharmacy, and the Allied Health Professions. The University President has the responsibility of organizing, directing, controlling, and managing the USUHS and its subordinate elements. The Board of Regents appointed by the President of the United States has held 20 meetings since July 1973 and a great deal of progress has been made over the past year. The Board members are: David Packard, Chairman, Board of Regents Chairman of the Board, Hewlett-Packard Company Former Deputy Secretary of Defense Palo Alto, California LT General Leonard D. Heaton, MC, USA (Ret) Vice Chairman, Board of Regents
Former Surgeon General of the U.S. Army Pinehurst, North Carolina
Durward G. Hall, M.D. Retired Member of the U.S. House of Representatives Springfield, Missouri Alfred A. Marquez, M.D. Physician and Surgeon in Private Practice San Francisco, California Joseph D. Matarazzo, Ph.D. Professor and Chairman Department of Medical Psychology University of Oregon Medical School Portland, Oregon Philip O'Bryan Montgomery, Jr., M.D. Professor of Pathology The University of Texas Health Science Center at Dallas Southwestern Medical School Dallas, Texas Charles E. Odegaard, Ph.D. President Emeritus, University of Washington Seattle, Washington H. Ashton Thomas, M.D. Executive Vice President, Louisiana State Medical Society Clinical Professor Emeritus of Otorhinolaryngology New Orleans, Louisiana Malcolm C. Todd, M.D. President, American Medical Association Surgeon in Private Practice Long Beach, California James R. Cowan, M.D. Assistant Secretary of Defense (Health and Environment) Washington, D. C. Vice Admiral Donald L. Custis, MD, USN The Surgeon General United States Navy Washington, D. C. LT General Robert A. Patterson, MC, USAF The Surgeon General United States Air Force Washington, D. C. LT General Richard R. Taylor, MC, USA The Surgeon General United States Army Washington, D. C.
(ex-officio)
(ex-officio)
(ex-officio)
(ex-officio)
Vol. 68, No. 1
Anthony R. Curreri, M.D., D.Sc. President, Uniformed Services University of the Health Sciences (ex-officio) Bethesda, Maryland Lionel Bernstein, M.D., Ph.D. Director of Program Operations Office of the Assistant Secretary for Health Department of Health, Education and Welfare Washington, D.C. The University was established as a separate agency
of the Department of Defense (DOD Directive 5105.45) with the chain of command flowing directly from the Secretary of Defense through the Board of Regents to the President, USUHS. This organizational structure will allow the University to function in a more autonomous manner with as little "red tape" as possible. The President, subject to the policies of the Board of Regents, shall have the responsibility and authority to: 1. Organize, direct, control, and manage the USUHS and its subordinate elements. 2. Serve as manager and coordinator of all resources and activities, including all University research programs. 3. Provide educational programs leading to a Doctor of Medicine or other advanced degrees in the health professions that will meet the standards of the appropriate accrediting agencies and appropriate medical and surgical specialty boards. 4. Provide advice and assistance on University matters to the Secretary of Defense, the Military Departments, and other DOD components. 5. Authorize and approve the collection and disbursement of funds received by the University through grants, endowments, bequests, or voluntary donations pursuant to regulations of the Department of Defense.
FACILITIES: The Armed Services and Appropriations Committees were well aware of the fact that the creation of a medical school "de novo" is ordinarily a long and arduous process covering a span from five to 10 years. A faculty and staff in all of the health disciplines must be laboriously recruited and assembled. In addition, costly capital outlays must be forthcoming to build facilities such as an administrative center, basic science buildings, laboratory and research facilities for the basic and clinical sciences, as well as teaching hospitals with an adequate patient census. Fortunately, many of these resources are available in the greater Washington, D.C., metropolitan area. There are in the greater Washington area, military and Federal medical resources whose full potential in contributing to an increased production of physicians have never been fully utilized. For example, the Armed Forces Institute of Pathology, the Armed Forces Radiobiology Research Institute, the National Library of Medicine, the National Institutes of Health, the Walter Reed Army Institute of Research, the Naval Medical Research Institute, the Walter Reed Army Institute of Nursing, the Walter Reed Army Medical Center, the National Naval Medical Center, and Malcolm Grow United States Air Force Medical Center.
Briefs
81
These Washington area facilities with their staffs, their patient populations, their clinics, laboratories, libraries, and classrooms already form the major assets for the creation of an outstanding medical education center. These facilities represent an enormous capital investment, all national assets, all currently operational, all mature institutions, many of which have national and international reputations. This new university will allow the Federal Government the opportunity to capitalize on these existing resources and thus meet at least a portion of the medical needs of our Armed Forces and eventually serve the Nation as a whole. The Board of Regents has selected the Armed Forces Institute of Pathology as the temporary site for the first class of approximately 36 students which is expected to be admitted in 1976. Some 50,000 square feet of space will be renovated so that multi-purpose laboratories, faculty office space, and some research space can be utilized for teaching the basic sciences to this group of students. Additional space will be available and will be shared with the staff of the Institute. The permanent site for construction of the University will be located on the reservation of the National Naval Medical Center, Bethesda, Maryland. Approximately 100 acres located in the southeast section have been identified for this purpose. It will be a tri-service institution with its own architectural identity and will be constructed in up to four increments. The first increment, a basic science building of approximately 170,000 gross square feet costing close to 15 million dollars, will be completed by the fall of 1976. Construction of the total University complex should be completed by 1980. The Joint Venture of Ellerbe, Dalton, Dalton, Little and Newport are the contractors for the project under the supervision of the Naval Facilities Engineering Command. The opportunities and challenges in creating such an institution are unparalleled in the annals of American health professional education. The creation of the University provides the opportunity for the Military Services to: (1) Recruit and educate health professionals with a career commitment to the Service, (2) Provide the University staff an environment necessary for coordinating basic and clinical science research programs, (3) Develop and conduct continuing education programs to insure military health professionals have ready access to a planned program of lifelong professional education, (4) Develop graduate level programs in all areas of health education and patient care required by the Military Services, and (5) Design and experiment with models of health care delivery suited to their unique needs. To insure military health professionals being educated in a team concept of health delivery, plans are proceeding to incorporate schools of medicine, dentistry, pharmacy, nursing, allied health, veterinary medicine, and graduate within the University. The space program has been developed to reflect several broad planning concerns of the Board of Regents and the President. The first of these concerns has
82
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
been the desire to achieve maximum economy in utilization of space ana optimum operational efficiency. Every effort has been made to reduce overall space requirements by planning for extensive shared use of basic science and general teaching areas reflecting the University's organizational and operational philosophies, goals, and objectives. Thefaculty and the students are the most important components of the University and eventually determine its ultimate character. The image that this school will have in the next decade depends greatly on how well it succeeds in its educational objectives. The faculty will be selected from both the civilian and military sectors. The salary schedules and tenure status of the civilian members of the faculty will be on a comparable basis with civilian academia. The tenure of military faculty will be determined by consultation between the Surgeons General and the Dean of the Medical School. The University will always give priority to quality rather than quantity although the total number of students enrolled in the programs is of importance in maintaining a career force. In view of the fact that the educational process in medicine also renders a service through medical care, the faculty must function in a dual capacity, namely as scholars and servants to the health care requirements of all the health science disciplines and with the personnel involved in health care delivery. The University also adheres to the principle that education's highest goal is the facilitation of human potential. Since the latter differs from individual to individual, educational programs must retain flexibility to accommodate a great spread of potentials. This can be accomplished either through diversity of programs or through liberal organization of individual programs, or both. Since medicine offers an amazing spread of professional career goals, medical education must offer educational opportunities for students ranging over a wide span of motivational and intellectual potential. In order to serve society and individuals best, an educational institution must retain considerable flexibility and guard itself against entrenched interests and rigidity. At the present time, the medical school plans to offer its students a 4-year broad based educational experience according to the more traditional methods which will enable its graduates to meet any exigency arising throughout the world as well as enter specialty training. The first two years will offer core courses in the basic sciences followed by the more innovative organ/system approach utilizing an interrelated interdisciplinary curriculum. It is also planned to expose the students to patient care and team health care starting in the first year. Additionally, course material will be so oriented as to reintroduce "humanism" in medicine. The last two years will emphasize clinical experiences in direct patient care and will allow the student to gain expertise in primary care settings, specialty areas, and the large ambulatory comprehensive health care communities in the military. Additional elective time will be offered the student in clinical and research facilities in this country and in areas in the world where a few diseases
JANUARY, 1976
rarely seen in this country are responsible for 80 percent of its morbidity and mortality. The University embraces the philosophy that medical education must be looked upon as a continuum beginning at the time the individual decides to become a physician until the moment he retires from the practice of his profession. To achieve this goal the faculty must extend its relationship from the basic sciences to the applied aspects of medicine serving the military community. The four-year program for the medical student must be related backward to the premedical experience and forward to graduate and continuing education. Underlying the premise is the realization that a medical school cannot teach in a four-year period all that a physician must learn and that any attempt to do so is not only frustrating but also may be harmful. Therefore, the future physician should be impressed with the need for continuing education and be provided with a program assisting him to develop his own education supported by the knowledge acquired during his formal training. Based on experience gained at other developing universities, the Board of Regents has agreed to develop the medical school faculty by selecting the Dean first, followed by departmental chairmen, and finally the departmental faculty. This logical approach should reduce to a minimum conflicts between faculty and the academic administrators. A Dean Search Committee composed of six nationally recognized health science administrators recommended, and the Board of Regents and the President with the approval of the Secretary of Defense, appointed Dr. Jay Philip Sanford, Professor of Medicine at Southwestern University Medical School in Dallas as Dean for the Uniformed Services University Medical School. At the present time, Search Committees and the Dean have begun the difficult task of selecting departmental chairmen as well as faculty for the School of Medicine. REQUIREMENTS FOR ADMISSION: The Medical College Admission Test along with three years of college are required; four years and a baccalaureate degree are recommended. The faculty encourages applications from students with a diversity of backgrounds. Required firm prerequisites are one full year (2 semesters or 3 quarters) of each of the following: English, General Chemistry, Organic Chemistry, Physics, General Biology and Mathematics. Because of their increasing value in the understanding of human behavior and activity, courses in the following are strongly recommended: Psychology, Social Sciences, History, Literature and Art. The application process consists of the standard AMCAS application form, three letters of recommendation from premedical faculty, and a personal statement describing the applicant's knowledge of and interest in a career as a medical officer in one of the uniformed services. Students will be selected by procedures recommended by the Board of Regents and prescribed by the Secretary of Defense. The actual selection process will be carried out by a faculty committee on Admissions and will be based upon an overall appraisal of the
Vol. 68, No. I
personal and intellectual characteristics of the candidates without regard to sex, race, religion, or national origin. The student must be a citizen of the United States. Inasmuch as the entering student will be a commissioned officer in one of the uniformed services, he or she must meet the physical and personal qualifications for such a commission and must give evidence of a strong commitment to serving his country as a medical officer. A personal interview and a complete medical examination will be required for those applicants under final consideration. Upon entering the first year class of the School of Medicine the student will be a commissioned officer and will serve on active duty in a paygrade of a Second Lieutenant in the Army and Air Force or Ensign in the Navy and Public Health Service. (Basic pay alone, excluding allowances, is currently $690 a month.) If current promotion policies continue the student can expect a promotion in rank to Captain (Lieutenant) upon receipt of the Doctor of Medicine degree. The graduating medical student is required to serve a period of obligation of not less than seven years. A period of time spent in military internship or residency training shall not be creditable toward satisfying this seven year obligation. A member of the program who, under regulations prescribed by the Secretary of Defense is dropped from the program for deficiency in conduct or studies, or for other reasons, may be required to perform active duty in an appropriate military capacity in accordance with the active duty obligation imposed. In no case shall any member be required to serve on active duty for any period in excess of a period equal to the period he participated in the program, nor may any such member be required to serve on active duty less than one year. RESEARCH: Although the University will place a major emphasis on education it can be categorically stated that an environment devoid of research, both basic and clinical, is bound to be pedantic and unimaginative. The opportunity to engage in the search for and discovery of new biomedical knowledge is essential if a University health science center is to succeed and develop leading educators and investigators for the military and society in general. The military medical departments, in addition to general medical research, have unique and extraordinary opportunities with their tremendous experience in trauma, burns, infectious disease, tropical medicine, preventive medicine, environmental behavior, blood preservation, vascular surgery, alcohol and drug abuse to become the leaders in these major areas. The military medical officer has not received adequate recognition for his productivity in the past, since he has not been able to relate to a university; he will now have that opportunity. The University and the military medical departments working together will have tremendous opportunities to develop and evaluate new models of education and health delivery because of the control that the military has over its personnel and patient population. What about next year? Following the selection of the basic science chairmen, hopefully by late spring 1975,
Briefs
83
selection of the key clinical department chairmen will take place. Faculty recruitment will be an ongoing process, with the chairmen of the various departments and the dean responsible for the selection of these individuals. All of the search committees will have military representation. Although it cannot be categorically stated as to what the military-civilian faculty mix will be now, it appears obvious to all, that with the existing excellent military staff at our teaching hospitals and research institutes, that the majority of the faculty will be military. Relationships between chairmen of departments at the University and the university medical centers (Bethesda, Walter Reed, Malcolm Grow) have been defined with the Surgeons General and approved by the Board of Regents. The President, Dean, and Departmental chairmen of the University will be responsible for student education at all levels and the adequacy of clinical affairs and research for the support of educational programs. The Surgeons General of the Military Departments and Medical Center Commanders will be responsible for hospital operations and will provide support to assure adequate clinical experiences. The chairman of a University department will be the department chairman at all three military medical centers (National Naval Medical Center, Walter Reed Army Medical Center, Malcolm Grow USAF Medical Center.) It should be stated that military medicine has had a great heritage which can be neither forgotten nor discarded. However, today in medicine, as in many other areas, many changes are occurring. What was appropriate in medical education and health care a decade ago may not be optimum today. Medical education and health care are faced with many challenges, but they can be met! The potential for the development of one of the greatest health science Universities in the world exists now and it can be accomplished with the cooperation of the Congress, the Department of Defense, the military departments and civilian academia. The pay and allowances of a medical student will be equivalent to that of a second lieutenant in the Army, Air Force, and Marine Corps or ensign in the Navy or Public Health Service. The total cost of training is borne by the Federal government. Moreover, each individual is provided, without charge, all books, supplies, and instruments required for the program. Students will be selected without regard to sex, national origin, religion, race, or marital status. The only restrictions on admission to the medical school are these, briefly stated: an individual must be a citizen of the United States, must meet the age and physical standards for holding a Regular commission in the Service, must have the requisite potential for succeeding in medical studies, must meet the course work prerequisites for entering the School, and must be motivated to spend a career in military medicine. The first few matriculating classes will be small, 35 to 50 in number. Minimum enrollment of 100 students in the freshman class is required by 1978. Further expansion to 150 students at each year level will take place in the future. A committee on admissions, made up of faculty members appointed by the medical school dean, will be responsible for
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
84
making admissions decisions. Entrants will be selected on the basis of demonstrated mental ability as well as aptitude, motivation, interest, maturity, and other attributes of a noncognitive nature. Grades will not be the sole criterion in making selections, although they will be an important factor in the selection process, as they serve as one of the indicants of intellectual ability. In all probability, no cutoff on grade average will be established for entering the School, but potential applicants should realize that the level of competition for entrance will be keen, with the preponderance of aspirants probably having a "B" or better average in their college work. It should also be
JANUARY, 1976
understood that there are no mitigating factors, neither singly nor collectively, that will fully compensate for substandard achievement at the undergraduate level. While such things as extra-curricular college activities, employment, graduate achievement, etc., will be taken into consideration in the selection process, none of these factors can substitute entirely for a low academic undergraduate performance. The tentative policy is that all aspirants will be required to take the Medical College Admission Test (MCAT). This test is administered twice annually-in May and October-by the American College Testing Program. Aspirants must make their own arrangements for taking the test.
THE PHYSICIAN'S ASSISTANT PROGRAM AT HARLEM HOSPITAL CENTER T.W. FONVILLE, M.D. Project Director
~ ~ ~.
The Physician's Assistant is a new member of the health care delivery team. An increasingly visible and highly qualified individual, the P.A. is employed by health care institutions and private practitioners. P. A. 's are physician extenders. They work as generalists under the supervision of a primary care physician, but are able to carry out many of the more routine procedures thus liberating the physician for complex decisions and tasks.
.;ii .I.i.: .
...
..
.... j; . . . . . . j.c....
A Physician's Assistant at work.
The P. A. is an answer to the increased demands by patients for medical services and the concomitant escalation in waiting time and deterioration of quality of delivery. The role of the P. A. somewhat encompasses that of the nurse and the laboratory technician and goes beyond. The training of a P. A. is similar to that of the medical student. The tasks that a P. A. performs are many: triage, routine history taking, preliminary physical examination, basic laboratory studies (CBC, U. A., bacteriologic smears), venipuncture, I. V.'s, initiation of emergency care, injections, rounds, record keeping, multiple screening procedures etc. The Physician's Assistant Program at Harlem Hospital, begun in 1971 as the only minority P.A. Program in the country, was instituted as a direct response to a felt need. Central Harlem, the community most directly served by Harlem Hospital, is by all available instru-
ments of measurement a medically impoverished area. Overcrowding, poor housing, high unemployment, alcoholism and drug addiction, and high crime, suicide, and disease rates are some of its all too familiar socioeconomic characteristics and are obvious to the most casual inspection. Central Harlem can be accurately described as an area in permanent social crisis. It was felt, therefore, that the introduction of intermediate level health personnel, i.e., Physician's Assistants would be the most feasible and beneficial response to this crisis on the part of the Harlem medical community. The talent pool immediately available for training was Harlem Hospital emergency room nurses' aides of long experience who were currently carrying responsibilities far beyond their job titles, and former Armed Forces medical corpsmen recently returned to the Harlem community from Viet Nam. An intensive 24 month curriculum was developed for 10 selected students, all of whom were high school graduates ranging in age from 22 to 33. The curriculum provided liberal arts as well as clinical training in physical diagnosis, medicine, surgery, psychiatry, pediatrics, Ob/Gyn, emergency care, and applied bio-science, includinganatomy, physiology, laboratory diagnosis, and pharmacology. Arrangements were made with Antioch College, an institution that has pioneered innovations in progressive and community-based education, to provide candidates successfully completing the program with Antioch College credits. Utilizing past work and life experience of each trainee as a means of granting up to two years of retroactive college credits, Antioch considered the students qualified and eligible for the bachelor's degree at the conclusion of only two years in the Harlem Hospital Program. Since its inception in 1971 the concept of the program has broadened. Having been proved highly successful and firmly established, the program is now national in scope and purpose. Students will come for
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Health Insurance Institute, Washington, D.C.; HON. HAROLD E. FORD, U.S. Congressman (D. Tenn.); PAUL B. CORNELY, M.D., professor emeritus, Department of Community Health Practice, Howard University; MR. ERIC SPRINGER, adjunct professor of hospital law, University of Pittsburgh; MR. DENNIS GOWIE, executive director, Provident Hospital, Balti-
JANUARY, 1976
more, Md., and MR. JEROME ASHFORD, executive director, National Association of Neighborhood Health Centers. The conference was sponsored by the Office of Health Resources Opportunity, Health Resources Administration of the U.S. Department of Health, Education and Welfare.
UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES Public Law 92-426 passed by the 92nd Congress in September 1972 already is being looked upon historically as one of the most important pieces of legislation relative to recruiting and retaining career motivated military medical department personnel for the Armed Forces. The law called for the establishment of a Uniformed Services University of the Health Sciences within 25 miles of the District of Columbia with authority to grant appropriate advanced degrees and to graduate not less than 100 medical students annually with the first class graduating not later than 1982. The second portion of this bill established the Armed Forces Health Professions Scholarship Program for the purpose of obtaining adequate numbers of commissioned officers on active duty qualified in the various health professions. The concept of a military medical school was first introduced in Congress in 1945 and subsequently reintroduced on numerous occasions. The authorizing legislation passed by voice vote in the Senate and in the House of Representatives by a vote of 310-13. Subsequent to the Congressional action, endorsements for the school have been received from civilian academia, organized medicine, the Department of Health, Education and Welfare, and many prestigious scientific organizations. The University will become the unique educational resource of the Department of Defense with the capability of extensive interdisciplinary professional training initially leading to the degree of Doctor of Medicine and as conditions permit, to the appropriate degrees or certification in Dentistry, Nursing, Pharmacy, and the Allied Health Professions. The University President has the responsibility of organizing, directing, controlling, and managing the USUHS and its subordinate elements. The Board of Regents appointed by the President of the United States has held 20 meetings since July 1973 and a great deal of progress has been made over the past year. The Board members are: David Packard, Chairman, Board of Regents Chairman of the Board, Hewlett-Packard Company Former Deputy Secretary of Defense Palo Alto, California LT General Leonard D. Heaton, MC, USA (Ret) Vice Chairman, Board of Regents
Former Surgeon General of the U.S. Army Pinehurst, North Carolina
Durward G. Hall, M.D. Retired Member of the U.S. House of Representatives Springfield, Missouri Alfred A. Marquez, M.D. Physician and Surgeon in Private Practice San Francisco, California Joseph D. Matarazzo, Ph.D. Professor and Chairman Department of Medical Psychology University of Oregon Medical School Portland, Oregon Philip O'Bryan Montgomery, Jr., M.D. Professor of Pathology The University of Texas Health Science Center at Dallas Southwestern Medical School Dallas, Texas Charles E. Odegaard, Ph.D. President Emeritus, University of Washington Seattle, Washington H. Ashton Thomas, M.D. Executive Vice President, Louisiana State Medical Society Clinical Professor Emeritus of Otorhinolaryngology New Orleans, Louisiana Malcolm C. Todd, M.D. President, American Medical Association Surgeon in Private Practice Long Beach, California James R. Cowan, M.D. Assistant Secretary of Defense (Health and Environment) Washington, D. C. Vice Admiral Donald L. Custis, MD, USN The Surgeon General United States Navy Washington, D. C. LT General Robert A. Patterson, MC, USAF The Surgeon General United States Air Force Washington, D. C. LT General Richard R. Taylor, MC, USA The Surgeon General United States Army Washington, D. C.
(ex-officio)
(ex-officio)
(ex-officio)
(ex-officio)
Vol. 68, No. 1
Anthony R. Curreri, M.D., D.Sc. President, Uniformed Services University of the Health Sciences (ex-officio) Bethesda, Maryland Lionel Bernstein, M.D., Ph.D. Director of Program Operations Office of the Assistant Secretary for Health Department of Health, Education and Welfare Washington, D.C. The University was established as a separate agency
of the Department of Defense (DOD Directive 5105.45) with the chain of command flowing directly from the Secretary of Defense through the Board of Regents to the President, USUHS. This organizational structure will allow the University to function in a more autonomous manner with as little "red tape" as possible. The President, subject to the policies of the Board of Regents, shall have the responsibility and authority to: 1. Organize, direct, control, and manage the USUHS and its subordinate elements. 2. Serve as manager and coordinator of all resources and activities, including all University research programs. 3. Provide educational programs leading to a Doctor of Medicine or other advanced degrees in the health professions that will meet the standards of the appropriate accrediting agencies and appropriate medical and surgical specialty boards. 4. Provide advice and assistance on University matters to the Secretary of Defense, the Military Departments, and other DOD components. 5. Authorize and approve the collection and disbursement of funds received by the University through grants, endowments, bequests, or voluntary donations pursuant to regulations of the Department of Defense.
FACILITIES: The Armed Services and Appropriations Committees were well aware of the fact that the creation of a medical school "de novo" is ordinarily a long and arduous process covering a span from five to 10 years. A faculty and staff in all of the health disciplines must be laboriously recruited and assembled. In addition, costly capital outlays must be forthcoming to build facilities such as an administrative center, basic science buildings, laboratory and research facilities for the basic and clinical sciences, as well as teaching hospitals with an adequate patient census. Fortunately, many of these resources are available in the greater Washington, D.C., metropolitan area. There are in the greater Washington area, military and Federal medical resources whose full potential in contributing to an increased production of physicians have never been fully utilized. For example, the Armed Forces Institute of Pathology, the Armed Forces Radiobiology Research Institute, the National Library of Medicine, the National Institutes of Health, the Walter Reed Army Institute of Research, the Naval Medical Research Institute, the Walter Reed Army Institute of Nursing, the Walter Reed Army Medical Center, the National Naval Medical Center, and Malcolm Grow United States Air Force Medical Center.
Briefs
81
These Washington area facilities with their staffs, their patient populations, their clinics, laboratories, libraries, and classrooms already form the major assets for the creation of an outstanding medical education center. These facilities represent an enormous capital investment, all national assets, all currently operational, all mature institutions, many of which have national and international reputations. This new university will allow the Federal Government the opportunity to capitalize on these existing resources and thus meet at least a portion of the medical needs of our Armed Forces and eventually serve the Nation as a whole. The Board of Regents has selected the Armed Forces Institute of Pathology as the temporary site for the first class of approximately 36 students which is expected to be admitted in 1976. Some 50,000 square feet of space will be renovated so that multi-purpose laboratories, faculty office space, and some research space can be utilized for teaching the basic sciences to this group of students. Additional space will be available and will be shared with the staff of the Institute. The permanent site for construction of the University will be located on the reservation of the National Naval Medical Center, Bethesda, Maryland. Approximately 100 acres located in the southeast section have been identified for this purpose. It will be a tri-service institution with its own architectural identity and will be constructed in up to four increments. The first increment, a basic science building of approximately 170,000 gross square feet costing close to 15 million dollars, will be completed by the fall of 1976. Construction of the total University complex should be completed by 1980. The Joint Venture of Ellerbe, Dalton, Dalton, Little and Newport are the contractors for the project under the supervision of the Naval Facilities Engineering Command. The opportunities and challenges in creating such an institution are unparalleled in the annals of American health professional education. The creation of the University provides the opportunity for the Military Services to: (1) Recruit and educate health professionals with a career commitment to the Service, (2) Provide the University staff an environment necessary for coordinating basic and clinical science research programs, (3) Develop and conduct continuing education programs to insure military health professionals have ready access to a planned program of lifelong professional education, (4) Develop graduate level programs in all areas of health education and patient care required by the Military Services, and (5) Design and experiment with models of health care delivery suited to their unique needs. To insure military health professionals being educated in a team concept of health delivery, plans are proceeding to incorporate schools of medicine, dentistry, pharmacy, nursing, allied health, veterinary medicine, and graduate within the University. The space program has been developed to reflect several broad planning concerns of the Board of Regents and the President. The first of these concerns has
82
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
been the desire to achieve maximum economy in utilization of space ana optimum operational efficiency. Every effort has been made to reduce overall space requirements by planning for extensive shared use of basic science and general teaching areas reflecting the University's organizational and operational philosophies, goals, and objectives. Thefaculty and the students are the most important components of the University and eventually determine its ultimate character. The image that this school will have in the next decade depends greatly on how well it succeeds in its educational objectives. The faculty will be selected from both the civilian and military sectors. The salary schedules and tenure status of the civilian members of the faculty will be on a comparable basis with civilian academia. The tenure of military faculty will be determined by consultation between the Surgeons General and the Dean of the Medical School. The University will always give priority to quality rather than quantity although the total number of students enrolled in the programs is of importance in maintaining a career force. In view of the fact that the educational process in medicine also renders a service through medical care, the faculty must function in a dual capacity, namely as scholars and servants to the health care requirements of all the health science disciplines and with the personnel involved in health care delivery. The University also adheres to the principle that education's highest goal is the facilitation of human potential. Since the latter differs from individual to individual, educational programs must retain flexibility to accommodate a great spread of potentials. This can be accomplished either through diversity of programs or through liberal organization of individual programs, or both. Since medicine offers an amazing spread of professional career goals, medical education must offer educational opportunities for students ranging over a wide span of motivational and intellectual potential. In order to serve society and individuals best, an educational institution must retain considerable flexibility and guard itself against entrenched interests and rigidity. At the present time, the medical school plans to offer its students a 4-year broad based educational experience according to the more traditional methods which will enable its graduates to meet any exigency arising throughout the world as well as enter specialty training. The first two years will offer core courses in the basic sciences followed by the more innovative organ/system approach utilizing an interrelated interdisciplinary curriculum. It is also planned to expose the students to patient care and team health care starting in the first year. Additionally, course material will be so oriented as to reintroduce "humanism" in medicine. The last two years will emphasize clinical experiences in direct patient care and will allow the student to gain expertise in primary care settings, specialty areas, and the large ambulatory comprehensive health care communities in the military. Additional elective time will be offered the student in clinical and research facilities in this country and in areas in the world where a few diseases
JANUARY, 1976
rarely seen in this country are responsible for 80 percent of its morbidity and mortality. The University embraces the philosophy that medical education must be looked upon as a continuum beginning at the time the individual decides to become a physician until the moment he retires from the practice of his profession. To achieve this goal the faculty must extend its relationship from the basic sciences to the applied aspects of medicine serving the military community. The four-year program for the medical student must be related backward to the premedical experience and forward to graduate and continuing education. Underlying the premise is the realization that a medical school cannot teach in a four-year period all that a physician must learn and that any attempt to do so is not only frustrating but also may be harmful. Therefore, the future physician should be impressed with the need for continuing education and be provided with a program assisting him to develop his own education supported by the knowledge acquired during his formal training. Based on experience gained at other developing universities, the Board of Regents has agreed to develop the medical school faculty by selecting the Dean first, followed by departmental chairmen, and finally the departmental faculty. This logical approach should reduce to a minimum conflicts between faculty and the academic administrators. A Dean Search Committee composed of six nationally recognized health science administrators recommended, and the Board of Regents and the President with the approval of the Secretary of Defense, appointed Dr. Jay Philip Sanford, Professor of Medicine at Southwestern University Medical School in Dallas as Dean for the Uniformed Services University Medical School. At the present time, Search Committees and the Dean have begun the difficult task of selecting departmental chairmen as well as faculty for the School of Medicine. REQUIREMENTS FOR ADMISSION: The Medical College Admission Test along with three years of college are required; four years and a baccalaureate degree are recommended. The faculty encourages applications from students with a diversity of backgrounds. Required firm prerequisites are one full year (2 semesters or 3 quarters) of each of the following: English, General Chemistry, Organic Chemistry, Physics, General Biology and Mathematics. Because of their increasing value in the understanding of human behavior and activity, courses in the following are strongly recommended: Psychology, Social Sciences, History, Literature and Art. The application process consists of the standard AMCAS application form, three letters of recommendation from premedical faculty, and a personal statement describing the applicant's knowledge of and interest in a career as a medical officer in one of the uniformed services. Students will be selected by procedures recommended by the Board of Regents and prescribed by the Secretary of Defense. The actual selection process will be carried out by a faculty committee on Admissions and will be based upon an overall appraisal of the
Vol. 68, No. I
personal and intellectual characteristics of the candidates without regard to sex, race, religion, or national origin. The student must be a citizen of the United States. Inasmuch as the entering student will be a commissioned officer in one of the uniformed services, he or she must meet the physical and personal qualifications for such a commission and must give evidence of a strong commitment to serving his country as a medical officer. A personal interview and a complete medical examination will be required for those applicants under final consideration. Upon entering the first year class of the School of Medicine the student will be a commissioned officer and will serve on active duty in a paygrade of a Second Lieutenant in the Army and Air Force or Ensign in the Navy and Public Health Service. (Basic pay alone, excluding allowances, is currently $690 a month.) If current promotion policies continue the student can expect a promotion in rank to Captain (Lieutenant) upon receipt of the Doctor of Medicine degree. The graduating medical student is required to serve a period of obligation of not less than seven years. A period of time spent in military internship or residency training shall not be creditable toward satisfying this seven year obligation. A member of the program who, under regulations prescribed by the Secretary of Defense is dropped from the program for deficiency in conduct or studies, or for other reasons, may be required to perform active duty in an appropriate military capacity in accordance with the active duty obligation imposed. In no case shall any member be required to serve on active duty for any period in excess of a period equal to the period he participated in the program, nor may any such member be required to serve on active duty less than one year. RESEARCH: Although the University will place a major emphasis on education it can be categorically stated that an environment devoid of research, both basic and clinical, is bound to be pedantic and unimaginative. The opportunity to engage in the search for and discovery of new biomedical knowledge is essential if a University health science center is to succeed and develop leading educators and investigators for the military and society in general. The military medical departments, in addition to general medical research, have unique and extraordinary opportunities with their tremendous experience in trauma, burns, infectious disease, tropical medicine, preventive medicine, environmental behavior, blood preservation, vascular surgery, alcohol and drug abuse to become the leaders in these major areas. The military medical officer has not received adequate recognition for his productivity in the past, since he has not been able to relate to a university; he will now have that opportunity. The University and the military medical departments working together will have tremendous opportunities to develop and evaluate new models of education and health delivery because of the control that the military has over its personnel and patient population. What about next year? Following the selection of the basic science chairmen, hopefully by late spring 1975,
Briefs
83
selection of the key clinical department chairmen will take place. Faculty recruitment will be an ongoing process, with the chairmen of the various departments and the dean responsible for the selection of these individuals. All of the search committees will have military representation. Although it cannot be categorically stated as to what the military-civilian faculty mix will be now, it appears obvious to all, that with the existing excellent military staff at our teaching hospitals and research institutes, that the majority of the faculty will be military. Relationships between chairmen of departments at the University and the university medical centers (Bethesda, Walter Reed, Malcolm Grow) have been defined with the Surgeons General and approved by the Board of Regents. The President, Dean, and Departmental chairmen of the University will be responsible for student education at all levels and the adequacy of clinical affairs and research for the support of educational programs. The Surgeons General of the Military Departments and Medical Center Commanders will be responsible for hospital operations and will provide support to assure adequate clinical experiences. The chairman of a University department will be the department chairman at all three military medical centers (National Naval Medical Center, Walter Reed Army Medical Center, Malcolm Grow USAF Medical Center.) It should be stated that military medicine has had a great heritage which can be neither forgotten nor discarded. However, today in medicine, as in many other areas, many changes are occurring. What was appropriate in medical education and health care a decade ago may not be optimum today. Medical education and health care are faced with many challenges, but they can be met! The potential for the development of one of the greatest health science Universities in the world exists now and it can be accomplished with the cooperation of the Congress, the Department of Defense, the military departments and civilian academia. The pay and allowances of a medical student will be equivalent to that of a second lieutenant in the Army, Air Force, and Marine Corps or ensign in the Navy or Public Health Service. The total cost of training is borne by the Federal government. Moreover, each individual is provided, without charge, all books, supplies, and instruments required for the program. Students will be selected without regard to sex, national origin, religion, race, or marital status. The only restrictions on admission to the medical school are these, briefly stated: an individual must be a citizen of the United States, must meet the age and physical standards for holding a Regular commission in the Service, must have the requisite potential for succeeding in medical studies, must meet the course work prerequisites for entering the School, and must be motivated to spend a career in military medicine. The first few matriculating classes will be small, 35 to 50 in number. Minimum enrollment of 100 students in the freshman class is required by 1978. Further expansion to 150 students at each year level will take place in the future. A committee on admissions, made up of faculty members appointed by the medical school dean, will be responsible for
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
84
making admissions decisions. Entrants will be selected on the basis of demonstrated mental ability as well as aptitude, motivation, interest, maturity, and other attributes of a noncognitive nature. Grades will not be the sole criterion in making selections, although they will be an important factor in the selection process, as they serve as one of the indicants of intellectual ability. In all probability, no cutoff on grade average will be established for entering the School, but potential applicants should realize that the level of competition for entrance will be keen, with the preponderance of aspirants probably having a "B" or better average in their college work. It should also be
JANUARY, 1976
understood that there are no mitigating factors, neither singly nor collectively, that will fully compensate for substandard achievement at the undergraduate level. While such things as extra-curricular college activities, employment, graduate achievement, etc., will be taken into consideration in the selection process, none of these factors can substitute entirely for a low academic undergraduate performance. The tentative policy is that all aspirants will be required to take the Medical College Admission Test (MCAT). This test is administered twice annually-in May and October-by the American College Testing Program. Aspirants must make their own arrangements for taking the test.
THE PHYSICIAN'S ASSISTANT PROGRAM AT HARLEM HOSPITAL CENTER T.W. FONVILLE, M.D. Project Director
~ ~ ~.
The Physician's Assistant is a new member of the health care delivery team. An increasingly visible and highly qualified individual, the P.A. is employed by health care institutions and private practitioners. P. A. 's are physician extenders. They work as generalists under the supervision of a primary care physician, but are able to carry out many of the more routine procedures thus liberating the physician for complex decisions and tasks.
.;ii .I.i.: .
...
..
.... j; . . . . . . j.c....
A Physician's Assistant at work.
The P. A. is an answer to the increased demands by patients for medical services and the concomitant escalation in waiting time and deterioration of quality of delivery. The role of the P. A. somewhat encompasses that of the nurse and the laboratory technician and goes beyond. The training of a P. A. is similar to that of the medical student. The tasks that a P. A. performs are many: triage, routine history taking, preliminary physical examination, basic laboratory studies (CBC, U. A., bacteriologic smears), venipuncture, I. V.'s, initiation of emergency care, injections, rounds, record keeping, multiple screening procedures etc. The Physician's Assistant Program at Harlem Hospital, begun in 1971 as the only minority P.A. Program in the country, was instituted as a direct response to a felt need. Central Harlem, the community most directly served by Harlem Hospital, is by all available instru-
ments of measurement a medically impoverished area. Overcrowding, poor housing, high unemployment, alcoholism and drug addiction, and high crime, suicide, and disease rates are some of its all too familiar socioeconomic characteristics and are obvious to the most casual inspection. Central Harlem can be accurately described as an area in permanent social crisis. It was felt, therefore, that the introduction of intermediate level health personnel, i.e., Physician's Assistants would be the most feasible and beneficial response to this crisis on the part of the Harlem medical community. The talent pool immediately available for training was Harlem Hospital emergency room nurses' aides of long experience who were currently carrying responsibilities far beyond their job titles, and former Armed Forces medical corpsmen recently returned to the Harlem community from Viet Nam. An intensive 24 month curriculum was developed for 10 selected students, all of whom were high school graduates ranging in age from 22 to 33. The curriculum provided liberal arts as well as clinical training in physical diagnosis, medicine, surgery, psychiatry, pediatrics, Ob/Gyn, emergency care, and applied bio-science, includinganatomy, physiology, laboratory diagnosis, and pharmacology. Arrangements were made with Antioch College, an institution that has pioneered innovations in progressive and community-based education, to provide candidates successfully completing the program with Antioch College credits. Utilizing past work and life experience of each trainee as a means of granting up to two years of retroactive college credits, Antioch considered the students qualified and eligible for the bachelor's degree at the conclusion of only two years in the Harlem Hospital Program. Since its inception in 1971 the concept of the program has broadened. Having been proved highly successful and firmly established, the program is now national in scope and purpose. Students will come for
