The small medical school, graduating 32 M.D.'s per year, has many advantages, several of which may be mentioned as being highly desirable: (1) Sixty percent of the new M.D.'s tend to practice near where they are trained, thus decentralizing the training will improve the distribution of physicians near the training area where the shortages are greatest. (2) The high quality of education can be maintained under university or college supervision. In fact, the quality of education could be much better in the smaller school because of the closer contacts between the faculty and students. The experience of excellent schools which have kept their classes small (such as Vanderbilt) or the early period of small classes of many schools which later expanded, is a case in point. (3) The total construction and operating costs of a small school are much less and if the costs were to be distributed among several local private, public, and Federal institutions they might be compatible with local resources. The costs per student thus will probably be somewhat higher than in the large programs, but not excessively so. (4) The smaller organization is more flexible and can respond more readily than the larger centers to curricular changes in program which are required to keep current with recent developments. (5) The smaller organization can be enlarged as the size of the population increases when both the need and the resources also increase and thus the community can support a larger program. These changes would be based upon experience and could occur at an appropriate time. (6) Even though small, the school can be a focus of postgraduate education and refresher programs for the members of the medical and health-related professions in the area or region. (7) The facilities can be much smaller and less costly in construction if there is enough land available for one-story, 30-year line, buildings as part of an existing medical facility. (8) The utilization of the local profession on a part-time basis can be more flexible and effective. Faculty are available from among the young, second-string, ranks of large centers or from newly trained postdoctoral scholars for whom no chairs or tenure positions exist in established centers. Faculty would be attracted by better personal educational and research facilities, the closer student-faculty relationship of the small school, less academic pressure, small-town, living and recreational conditions for their families. It is exceedingly important to keep the commitments within the reach of the local resources. A medical school graduating 32 M.D.'s per year is taken as the model. The minimum requirements which can justify a location for a small medical school graduating 32 M.D.'s and others per year are: (1) A stable, vigorous, metropolitan area of about 100,000 population; (2) A county medical association of about 150 actively practicing M.D.'s with a goodly proportion of board certified specialists; (3) At least 300 "acute" beds in modern community and private hospitals capable of accommodating a small, well organized, undergraduate teaching program and of supporting appropriate internships and residencies. (4) A Veterans' Administration facility hospital with sufficient beds to support an educational program and capable of developing and supporting an appropriate postdoctoral teaching and research program and an appropriate part of the undergraduate program. (5) One or more State or private colleges of high quality with strong programs in the sciences and a graduate school. With such facilities it is necessary to have a high, enduring interest in, and support of, the medical school by the local county medical association, the community leaders, the educational institutions, and the governing boards of the tobe-affiliated hospitals, as well as the sympathetic support of the Governor and appropriate State officials. Additional and new requirements to implement the program are essential if full advantage is to be taken of the existence of a Veterans' Administration facility and the other resources available. As a starting mechanism in some communities (Boise, Idaho, and Amarillo, Tex.), a nonprofit corporation already has been organized with sufficient funds to undertake feasibility studies and to provide financial support to initiate anc implement the program. Some such mechanism is necessary in order to mobilize and coordinate and focus the community's resources, and to assure the community of the stability and practicality of the plans. Where a strong State-supported ducational institution already exists in the community, such a nonprofit corporaion, while not vital to the initial success of the program, could be very helpful □ a great many ways throughout the succeeding years. In most States it will e necessary to coordinate the newly proposed medical school with official State and regional planning bodies for medical school, health-related and, other instituions. New congressional legislation will be needed to authorize the VA to make a contract with the other institutions in the community to be associated with it in ›lanning, organizing, funding, building, and operating the new medical school. such legislation is urgently required, anyway, to improve and stabilize and legalize he present informal relationships which the Veterans' Administration now has with existing medical schools. A sample bill is attached for consideration. Certain contractual relationships and local mutual understandings are necesary to undertake this rather complex relationship: (1) To delegate or assign the responsibility for the education and research programs, including the issuance of degrees and certificates to the educational institution or institutions concerned. (2) To stipulate the role of the affiliated hospital boards, including the sharing of additional costs for space, facilities and operation of part of the teaching program in their off-site facilities. (3) To stipulate the role of the VA facility or other institutions which are to provide their on-site buildings and facilities and certain operating and housekeeping costs for the new school. (4) To provide the administrative mechanisms for coordination and implementation of the new program, including negotiation and arbitration of changes required from time to time as the need arises. This mechanism should include the regular negotiations of the budgetary needs of the medical school. (5) To identify the autonomy of purpose of each of the affiliated institutions which might be separate from or coordinated with the teaching program, as the case may be. (6) To provide the administrative mechanisms for participation in funding and grants such as may be available to any medical school (Public Law 88129, "Health Professions Educational Assistance Act of 1963"; Public Law 88-156, "Maternal and Child Health and Mental Retardation Planning Amendments of 1963"; Public Law 88-164, "Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963; Public Law 88-443 "Hospital and Medical Facilities Amendments of 1964"; and Public Law 88-581 "Nurse Training Act of 1964") and others which may become appropriate from time to time. In the absence of the VA facility a large, well-established, well-financed hospital or clinic group might serve to be the focus of the school (Mayo's, White's, Henry Ford Hospital, etc.) Tentative inspection of possibilities indicates that between 30 to 40 sites around the Nation having equivalent or more than the minimum resources should be studied as possible locations for a small medical school. Construction of one-story buildings such as those for junior colleges with a 30- to 40-year life expectancy would reduce both the construction costs and construction time and permit great flexibility for later modification and change. Consideration should be given to placing the construction of the medical school buildings close to or attached to existing VA structures so as to take maximum advantage of existing utilities and to permit ready access by students and faculty to the ward and other patient areas in these structures. While the goal would be to increase the number of general practitioners, the yield of the desired specialists from such schools cannot be identified at this time, but it is not unreasonable to expect that it would be a considerable number of the M.D. graduates since the national trend is greater than 50 percent. Even a low yield of specialists would have an appreciable effect since from this group would come the specialist staff for outlying decentralized mental retardation and mental health or other health-related facilities and centers near the location of the small schools. The situation and the resources will vary greatly from one community to another. There is nothing magical about the size of the number of M.D.'s to be graduated. The determining point is the resources with which to maintain a stable operating level. It is necessary to provide about 15 departments in order to present a broad curriculum including the major disciplines. While it is possible with teaching assistants chosen from among the graduate students and residents for one prefessor to cover some disciplines, most of them will require at least two full-time academicians. Thus a total of 15 2-man departments is shown in the budget a a faculty of 30 full-time academicians. (See fig. 2.) In respect to size and using numbers (for estimates only) it has been found by several of the newer schools (Stanford) that 16 students is a basic unit for sections or laboratories and the 32 student school thus has two units and two academicians per department. If it is found from the feasibility study that the resources can be stabilized at å larger level, then the real costs will rise at about one-half of those costs and spaces indicated in figures 2 and 3 per each 16-unit increase in class size. It is dangerous to look for lower costs by adding to the faculty loads or by the crowding of space, if the educational quality is to be maintained. It is much safer to start small and keep within the resources. Most of the existing schools are in trouble because they are over committed, under budgeted and have insufficient space for their programs. The space for the faculty research is the most important element for attracting young academicians of high quality. The minimum net useful research space per department is 1,575 square feet. The need for research space will vary among the disciplines and no doubt within a decade more space will be required, particularly for special projects. As the faculty and school matures the faculty unit research space may level off at an average of about 1,500 ASF per academician. The costs shown in figure 3 are for metropolitan areas and probably are higher than will be found in outlying areas. Recent inspection of costs for one-story laboratory type buildings-concrete slab and block walls in outlying cities indicates that construction costs may be as low as $25 per square foot assignable. The feasibility study made for each area should give the proper values. No account is taken of opportunities for occupancy of remodeled facilities. HEALTH RELATED PROFESSIONAL PERSONNEL Numerous studies have attested to the short supply of all of those participating in the medical and health-related fields. These studies are well enough known so as not to require review here. It would be highly desirable therefore to establish ratios or some relationship to the numbers required to support the new M.D. graduate, either directly under his supervision or indirectly in the community's health related programs where the doctor is the focal point. In building a medical school and center it is therefore important to include the training of a proper proportion of these health-related professional personnel and to provide space and budget for the professional training program of each. The preprofessional undergraduate educational requirements can be negotiated with the local and other educational institutions much as in the case of the premedical requirements. A considerable increase in enrollment of preprofessional students may be required over that planned by most small institutions and some additional Federal assistance may be needed both in classrooms and faculty to meet the goals. (Public Law 88-204-Higher Education Facilities Act.) An additional academic administrator probably as assistant dean in charge of health-related curriculums and staff must be added to the medical school dean's office for admission and curricular control of the clinical instruction of these students registered for certification or degree courses in the health-related areas. These students should receive their clinical instruction and practice training in the same environment as the medical students and be integrated among the affiliated hospitals and other medical installations together with the medical students. The same policies and principles would govern the clinical training of other healthrelated professional students for postdoctoral programs. Nursing Extensive inquiry indicates that there has been no formal analysis made of the number of nurses or other health-related professionals which should be trained in proportion to the number of M.D.'s graduated. There is a large uncertainty in reaching any specific number or ratio because of the dropout rate due to marriage or change into another career after the training period. Also many nurses, social workers, therapists, etc., will have a double training and use such as in the case of the nurse-secretary, nurse-technician role or a specialty in some clinical field (psychiatry, surgical, public health, schools, industry, etc.). Thus only a sophisticated guess can be made which some may question because of the seemingly large number indicated. For in order to supply this very important manpower without which the doctor cannot practice effectively, it appears hat 10 or more general duty nurses (R.N.) should be graduated per M.D. graduated each year. For a medical school class of 32, the nursing student training evel for R.N. certificates should range between 320 to 350 graduates per year. Little account has been taken of any such ratio in providing for nurses to serve community needs which is why it is estimated that the Nation needs 20,000 more nurses. Other health-related professional personnel In areas other than nursing where the chief of a service program is qualified, one or two properly qualified students can be given their clinical professional training without additional salary or space since they would not crowd the service programs and might offer some assistance as well. Where an advanced degree is involved the usual graduate division regulations of the college must be carried out and any space requirements for their thesis would be negotiated with a department of the medical school. Certificate and degree programs might include, in addition to nursing, those in medical social welfare, clinical psychology, technicians of several kinds, therapists and counselors and other specialties. The variety of these would depend upon the needs of the region and the educational opportunities. Much of the training costs might be borne by special grants under existing Federal legislation. Dental education The shortage of dentists is well documented and need not be reviewed here. In evaluating the health needs of an outlying city of 100,000, the resources rebuired to build a dental school should be determined, also. The ratio of M.D.'s grdauated to D.D.S.'s graduated per year is not well established but in recently built medical centers the ratio is nearly 1 to 1. The ratio between D.D.S.'s and dental technicians graduated per year should also be 1 to 1. The source of clinical teaching cases would come from the economically disadvantaged population. There would be more than enough clinical material to supply the teaching program of a dental school graduating 32 D.D.S.'s per year in every metropolitan area of 100,000 people. The dental school program constructed physically as part of the medical and nursing educational complex can utilize many parts of the other program but enlargements of some and duplication of others is required to keep the quality high and to assure proper educational services to the students. Payment for part-time instruction by the practicing dentists and dental specialists of the area in the dental teaching clinic is common in most dental schools and should be taken advantage of. However, for a class of 32 D.D.S.'s graduated per year there should be at least 4 full-time clinical dental academicians and 6 full-time basic science academicians. The latter should be regular members of the basic science departments of the medical school, specially selected for their knowledge of dental problems. Considerable mutual assistance by the pooled faculty in the dental-medicalhealth-related student programs provides both strength and breadth to the total program. As is the case for other academicians the benefits derived from the availability of research laboratory space is a primary factor in the procurement of high-quality faculty. If the dental school were to be separated physically or be built by itself without the other units, then the costs for library, lecture halls, animal care, and other shared facilities and the faculty requirements would be considerably higher. General considerations No cost has been estimated for the utilities and janitorial services or maintenance and replacements because these will vary greatly with the local conditions and negotiations. Whether "for free" or not, another $100,000 per year should be considered as a not unreasonable charge for the utilities and janitorial and other services for the three programs. The budget estimates are obviously oversimplified, and there is considerable leeway for unidentified items of this sort. However, the totals are probably close to reality for they are close to the budgets of several small medical schools during this level of operation. The enlightened self-interest of the several participating groups, the Veterans' Administration, the to-be-affiliated community hospitals and the local college of colleges, permits a great deal of sharing or absorption of many of these costs. Attached is the foreword to a House Committee Print No. 72, 89th Congress, May 12, 1965, "Facilities for Education in Veterans' Administration Hospitals" by Congressman Olin E. Teague, chairman, Committee on Veterans' Affairs, which reflects on the possibly greater role of the VA in medical and paramedical education in the VA's self-interest. Keeping within the resources of an area or region and by placing these medical training complexes about the country in proportion to the population to be served, a better distribution of these services can be brought about. A partial list of potential locations is attached to indicate the possibilities. Once an examination of the possible locations for small institutions is carried out, it is likely that more medical training institutions can be started and carried on than is apparent at first. There are some who will not yet be ready for s variety of circumstances. There no doubt will be some who can afford larger intermediate goals at levels of 48 or 64 M.D.'s graduated per year. Federal assistance should be adjusted so that the goals are always in keeping with the local resources and to avoid overcommitment of the programs. It should not be overlooked that most of the money expended in these projects is spent in the local community, making a not inconsiderable contribution to its economy. Recommendation It is recommended that the Department of Health, Education, and Welfare and the Veterans' Administration, through their advisory committee organizations, and granting authority, undertake to support feasibility and other studies leading to the implementation of these small medical schools and centers in eonnection with the Veterans' Administration program and with appropriate budgetary support from both Federal agencies as the President and the Congress may elect to provide. FIGURE 1.—Minimum community requirements for consideration of site for a small medical school (32 medical students per class) Metropolitan community of at least 100,000 population. Community (acute) beds of 300 or more whose trustees are willing to undertake their part of the medical school program. VA facility of about 200 beds in the general medical and surgical category and other facilities. A local college or university of high educational quality, willing to accept the responsibility for the educational and research programs. A nonprofit corporation with funds sufficient to undertake a feasibility study and dedicated to initiating and implementing the program. FIGURE 2.-Annual operating minimum teaching, budget, estimated 1 1 Research, special training budgets, fellow ships and scholarships supplied by grants. |