The Medical School's Mission and the Population's Health

The Medical School's Mission and the Population's Health

Kerr L. White Editors Julia E. Connelly The Medical School's Mission and the Population's Health Medical Education in Canada, The United Kingdom, The United States, and Australia Proceedings of a Conference Sponsored by The Royal Society of Medicine Foundation, Inc., and The Josiah Macy Jr. Foundation December 9-12, 1990, Turnberry Isle, Florida With 20 Illustrations Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Hong Kong Barcelona Budapest

Kerr L. White (Retired Deputy Director for Health Sciences, The Rockefeller Foundation, New York) 2401 Old Ivy Road, #1410 Charlottesville, V A 22901-3470 USA Julia E. Connelly Associate Professor of Medicine University of Virginia Medical Center Charlottesville, V A 22908 USA Library of Congress Cataloging-in-Publication Data The Medical school's mission and the population's health: medical education in Canada, the United Kingdom, the United States, and Australia / Kerr L. White, Julia E. Connelly, editors. p. cm. Based on a meeting organized by the Royal Society of Medicine Foundation and the Josiah Macy, Jr. Foundation, Dec. 9-12, 1990 at Turnberry Isle, Fla. Includes bibliographical references and index. ISBN -13:978-0-387-97772-0 1. Medical education-congresses. 2. Medical education policy -Congresses. 3. Public health-congresses. 1. White, Kerr L. II. Connelly, Julia E. III. Royal Society of Medicine Foundation. IV. Josiah Macy, Jr. Foundation. [DNLM: 1. Public Health-education-Australia-congresses. 2. Public Health-education-Canada-congresses. 3. Public Health -education-great Britain-congresses. 4. Public Health-education- -United States-congresses. 5. Schools, Medical-Australia- -congresses. 6. Schools, Medical-Canada-congresses. 7. Schools, Medical-Great Britain-congresses. 8. Schools, Medical-United States-congresses. W 19 M4913 1990] R735.A2M43 1992 61O'.71'I-dc20 DNLM/DLC for Library of Congress 91-5154 Printed on acid-free paper. 1992 Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1992 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Acts, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production coordinated by Chernow Editorial Services, Inc. and managed by Christin R. Ciresi; Manufacturing supervised by Jacqui Ashri. Typeset by Edwards Brothers, Inc., Ann Arbor, MI, USA. 9 8 7 6 5 4 3 2 1 ISBN-13:978-0-387-97772-0 DOl: 10.1007/978-1-4613-9189-0 e-isbn-13:978-1-4613-9189-0

Foreword Medical schools exist as part of a complex educational and health care system with affiliations to universities, teaching hospitals, outpatient clinics, students, and communities. Those of us who serve as trustees and volunteers on boards and committees of medical schools carry obvious responsibilities for the performance of the institution with regard to those affiliations, including those that relate to the community. By what criteria, and by what standards, do we as trustees assess that performance? For trustees of medical schools, I suggest that the most important criteria are those concerned with the purpose for which the school was originally established and those that relate to the community that supports it and is served by it. For a medical school performance criteria should be defined in a statement of purpose: the "mission" of the school. This mission statement should provide trustees with direction on such vital matters as the following: What does the medical school seek to accomplish? Whom does it serve? Where is it going? What is the relationship to the geographic region or other community that it may seek to serve? Such questions are stated more easily than they are answered, but they should be asked. For trustees who are responsible for the education of students, the management of faculty, and the stewardship of funds they are a matter of serious concern. Is there a "community" or "population" to be served by the medical school? If so, how is it to be defined? No doubt, as an educational institution, the medical school is concerned with the education and training of its students. At the same time, as part of the health care system, is the school also to be charged with any responsibility for understanding and meeting the health care needs of the population or its "community"? This volume is the outcome of a meeting organized by the Royal Society of Medicine Foundation and the Josiah Macy Jr. Foundation to discuss that question. Those who participated had, for the most part, already concluded that some responsibility does exist. They came together, therefore, to exv

vi Foreword amine how medical schools in the United States, United Kingdom, Canada, and Australia can profit from each other's experience in organizing medical education, so that faculty and students recognize more fully their responsibility for understanding and meeting the health needs of the community. The 37 participants from the four countries represented perspectives in medical education, clinical practice, epidemiology, and government. In their planning, the organizers of the meeting were guided by a series of questions they believed to be relevant in all four countries. How should physicians be educated to respond most effectively to the anticipated health care needs of the population as well as to the needs of individual patients? To what extent is the "social contract of medicine" at odds with or in harmony with the value of diversity in medical education? How do medical schools determine their collective responsibilities and activities? How do medical schools individually and collectively view their obligations for the health of the public? To what extent can medical schools be held accountable for critical problems in health care (e.g., escalating costs, overspecialization, accessibility), and how should they respond when a community is beset by huge problems (an epidemic such as AIDS) and a need to find a system of health care that will provide coverage for all its citizens? I was delighted to have participated, as President of The Royal Society of Medicine Foundation, in the lively discussion of the excellent papers and critiques presented at the meeting. We commend this volume to you as an important contribution to a vital part of the national debate on health care policy. Hopefully, it will assist you in framing your own questions, or, at least, shaping your beliefs as to the role and mission of the medical school in contributing to the health of the community. Arthur J. Mahon President The Royal Society of Medicine Foundation

Preface William G. O'Reilly, Executive Director of the Royal Society of Medicine Foundation, Inc., New York (the North American arm of the Royal Society of Medicine), and Thomas H. Meikle, Jr., M.D., President of the Josiah Macy Jr. Foundation, New York, conceived the idea for the Conference resulting in this volume; the latter Foundation financed it. The two sponsors perceived urgent problems facing medical schools in four countries that have similar approaches to medical education, research, and patient care. In their view the present situation warranted an exploration of common themes underlying the malaise besetting medical educators in these countries. Of greater importance was the prospect of collaborating in the search for fundamental changes needed in the preparation of physicians to cope with society's health problems. The Planning Committee for the Conference consisted of Mutya San Agustin Sir Douglas Black Sir Christopher Booth Julia E. Connelly David S. Greer David H.H. Metcalfe Thomas S. Inui Victor R. Neufeld Lionel E. McLeod William G. O'Reilly Thomas H. Meikle, Jr. Robert S. Spasoff Kerr L. White (Chair) To generate fruitful discussion during the Conference, this Committee, meeting in June 1989, prepared a statement of its principal objectives. These included the need to develop strategies for expanding the medical school's mission to embrace the population perspective, in addition to the biomedical and individual patient-physician perspectives that now dominate most of Western medical education. To this end the Planning Committee drafted five recommendations. In addition to these recommendations, the statement of objectives included possible mechanisms for ensuring their enforcement through examinations, certification, accreditation, and licensure. Such measures should reassure the public that medical schools are indeed being responsive to concerns about its health status and health services. Promulgation of a mission statement by each medical school should relate the faculty's vii

Vlll Preface educational, research, and patient care commitments to the present and projected health needs of the populations they serve, and should define the population-based competencies required to accomplish the mission. The Planning Committee selected the authors and participants; all the first choices accepted. Papers and topics were chosen on the basis of the five possible recommendations drafted by the Committee. The authors and topics selected for the Conference were designed to provide theoretical discussions, illustrative data, and practical examples of approaches to meeting the population's health needs as reflected in the five draft recommendations. The authors' outlines for the papers were reviewed by all members of the Planning Committee and comments returned to them; the first drafts of the full papers were similarly reviewed. Final versions of all the papers, together with three additional written discussions, were circulated to all participants three weeks prior to the meeting. These arrangements assured ample time for informed debate by the 37 participants from the four countries over the four days of the Conference at Turnberry Isle, December 9-12, 1990. Several authors revised their papers slightly following the meeting and we have edited them by removing most laudatory and redundant passages, maintaining reasonable consistency of style, and using American spelling. The basic messages, together with the three discussants' comments for each contribution, should have survived intact. From reports prepared by eight rapporteurs the editors have distilled, without attribution, additional comments on the issues raised. The final sets of definitions and recommendations reflect a strong consensus among the Conference Participants; not everyone will agree with every element of each statement but as a body they all endorse the general thrust of the ideas recounted in Chapter 9. If these ideas generate further debate within each of the four countries, and, more importantly, within individual medical schools, this exercise will have achieved its objectives. Timely cooperation by everyone enabled the editors to prepare the manuscripts for rapid publication. With this and other tasks William O'Reilly, his assistant Betty Chase, and Julia E. Connelly's assistant Dale Vandervoort, provided most effective support. We are grateful to all of them, as well as to our colleagues in this endeavor. We trust our collective efforts will contribute to an international debate about how, not whether, medical education must change. Kerr L. White Julia E. Connelly

Contents Foreword-Arthur J. Mahon... v Preface... vii Contributors... xi 1 Redefining the Mission of the Medical School Kerr L. White and Julia E. Connelly Discussion: David S. Greer. John D. Hamilton. and David A. Shaw 2 The Social Contract and the Medical School's Responsibilities.. 23 Thomas S. I nui Discussion: David Axelrod. Sir Christopher Booth. and Ian R. McWhinney 3 Measuring the Burden of Illness in General Populations Michael G. Marmot and Anthony B. Zwi 60 Discussion: Sir Douglas Black, Robert A. Spasoff. and Thomas S. I nui 4 The Potential and Organization of Health Intelligence Units 113 Victor R. Neufeld and Robert A. Spasoff Discussion: Lord Butterfield, Harry S. Jonas. and Lionel E. McLeod 5 Population-Based Medicine: A Case Study from a Traditional School... 132 Mutya San Agustin ix

x Contents Discussion: Sir David Innes Williams, Arthur Kaufman, and Mamoru Watanabe 6 A Community and Population-Oriented Medical School: Newcastle, Australia... 164 John D. Hamilton Discussion: Harvey Barkun, George I. Lythcott, and David H.H. Metcalfe 7 Essential Institutional Competencies for Population-Based Education... 208 David H.H. Metcalfe Discussion: Roger J. Bulger, Victor R. Neufeld, and Peter Richards 8 Essential Population-Based Competencies for Undergraduate and Postgraduate Medical Students... 234 Robert D. Cohen Discussion: Jo Ivey Boufford, Paula L. Stillman, and John Wade 9 Balancing Perspectives... 257 Kerr L. White and Julia E. Connelly Conference Participants... 267 Index... 271

Contributors ROBERT D. COHEN, M.D. Professor of Medicine, London Hospital Medical College, University of London, Whitechapel, London EI IBB, England JOHN D. HAMILTON, M.D. Dean and Professor of Medicine, Rankin Drive, University of Newcastle, Newcastle, NSW 2308, Australia THOMAS S. INUI, M.D. Professor and Head, General Internal Medicine and Professor of Health Services, School of Medicine, 105A Harborview Hall, University of Washington, Seattle, WA 98104, USA MICHAEL G. MARMOT, M.B., Ph.D. Professor of Community Medicine, 66-72 Gower Street, University College and Middlesex School of Medicine, London WCIE 6EA, England DAVID H.H. METCALFE, M.B., B.S. Professor and Chairman, Department of General Practice, Rusholme Health Centre, Walmer Street, University of Manchester Medical School, Manchester M14 5NP, England VICTOR R. NEUFELD, M.D. Director, Centre for International Health and Professor of Medicine and Clinical Epidemiology, HSC-3N44B McMaster University, Hamilton, Ontario L8N 3Z5, Canada MUTYA SAN AGUSTIN, M.D. Director, Department of Ambulatory Medicine, North Central Bronx Hospital, 3424 Kossuth Street, Room 4M-08, Montefiore Medical Center, Bronx, NY 10467, USA ROBERT A. SPASOFF, M.D. Professor and Chairman, Department of Epidemiology and Community Medicine, 451 Smythe Road, University of Ottawa, Ottawa, Ontario KIH 8M5 Canada ANTHONY B. ZWI, M.B., Ch.B. Department of Epidemiology and Public Health, 66-72 Gower Street, University College and Middlesex School of Medicine, London WCIE 6EA, England. Present address: London School of Hygiene, Keppel Street, London WCIE 7HT, England xi