The past five years have seen enormous changes in all fields of health sciences. There have been unprecedented research discoveries; advances in health related technology and informatics. Along with these innovations, there has also been a revolution in the economics of health delivery systems. Market driven forces have transformed how health services are organized and made available to patients. HMOs and Managed Care Systems have largely replaced traditional modes of patient care, such as fee for service. This has meant that many assumptions concerning the patient/doctor relationship have changed to meet the demands of systems seeking to provide lower cost health care. A greater emphasis of efficiency, accountability and cost effectiveness has emerged. Though the expanding new systems of care have more than their share of problems and critics, they have altered the current dialogue concerning how new physicians and other health care providers should be educated.

It was in recognition of these significant changes occurring in the health sciences professions that the Universitywide Academic Senate/Academic Council, following a request from the University Committee on Educational Policy (IJCEP), established a Health Sciences Education Committee in 1996. UCEP deemed that the emergent health sciences education policy issues might be more appropriately discussed by a full group of health sciences educators, representing all of the UC health sciences programs. Because of the wide scope of these programs throughout the UC system, it was not feasible for these issues to be discussed in their complexity by UCEP itself.

The Academic Council agreed that such a new committee, which would serve as a forum for health sciences educators, should report to the Universitywide Academic Senate.

MEMBERSHIP consists of a total of eighteen members. Fifteen members represent the health sciences programs: two members from UC Berkeley, representing Optometry and Public Health; two from UC Davis, representing Medicine and Veterinary Medicine; one from UC Irvine, representing Medicine; four from UC Los Angeles, representing Dentistry, Medicine, Nursing and Public Health; one from UC San Diego, representing Medicine; and four from UC San Francisco, representing Dentistry, Medicine, Nursing, and Pharmacy. In addition, there would be one at-large member from the Biomedical Program at UC Riverside. There would also be three ex offlcio members representing UCEP, University Committee on Planning and Budget (UCPB), and University Committee on Research Policy (UCORP).

The Chair, Vice Chair, and members are appointed by UCOC. The Chair will serve for one year to be succeeded by the Vice Chair. The term of appointment will be for three years, with one of them rotating off each year. Currently, the Chair is Leonard Zegans, M.D. from UCSF, and the Vice Chair is James Fallon, Ph.D., from UC Irvine.

The Committee was charged with the following duties:

1. Recommend policies and procedures for maintaining excellence in health sciences education and training programs as well as diversity of the various health sciences educational programs.
2. Strengthen, via coordination, the health sciences education programs across the campuses.
3. Recommend strategies to assure that basic and clinical research continues to serve as the foundation for teaching current health sciences principles and practice.
4. Encourage exchange and interdisciplinary contributions to the planning and problem solving of issues, which will affect health sciences education.

II. ORGANIZATION AND FUNCTIONING OF THE COMMITTEE

Following the establishment of the Committee, representative members were appointed and the Committee held its first meeting on April 29, 1997 at UCSF. At this time, the Committee was addressed by Dr. Sandra Weiss, Chair of the Academic Council, who expressed the hope that the committee would advise the Senate and through the Senate the Office of the President and the Regents regarding issues of importance in health sciences education. It was decided at this time that the committee would visit each site of the represented programs at all six campuses to meet with faculty, administrators and students to gather data on the problems, issues and changes that they see confronting health sciences education at their location. This would permit the committee to get an idea of the facilities and context of each program and be enriched by the comments of the invited guests.

The committee began to draw up a series of questions and concerns about the contemporary state of academic health sciences programs which would inform the questions that it posed during its campus visits and its own internal discussions. Among them were the following:

• What is/are the core mission(s) of each of the health sciences programs?
• Is there a set of core professional and academic values, which should inform education in each of the programs? If so, what are they?
• What are the most salient issues regarding the role of the faculty in the health sciences? Are there emerging concerns regarding recruitment, retention, promotion, diversity, impact of clinical responsibilities on teaching, the nature of series appointment on faculty rewards and activities?
• Are there significant problems in student admissions? Are there sufficient diversity, numbers and quality among our applicants? What are the most important issues relating to UC competing successfully for outstanding candidates? Should there be a reconsideration of standards and requirements for admission to our programs? Is there a need for more or fewer programs?
• Are there significant issues concerning the role of health sciences programs within each parent campus with regard to resource allocation, promotions, governance, etc.?
• How have market driven forces in the health care market impacted on the organization and quality of education?
• What significant changes are taking place regarding the revision of curriculum in the various Schools to reflect changes in research, service delivery, economics and practice technology in each of the fields?
• Are there new innovations in techniques and philosophy of delivering health sciences education (problem-oriented classes, smaller groups, simulated patients, etc.), which are being instituted within the various programs? What are the evaluations of the success and difficulties with these innovations?
• Do each of the programs perceive ways in which certain educational problems can be best solved by creating well integrated UC-wide networks and structures? If so, what kind of program components would benefit from such integration?
• How are continuing education programs organized within each site? Are there ways in which ongoing educational needs of graduates can be better served?
• Describe the issues and problems with the organization, function and structure of the academic medical center at each site. Are there problems which impinge upon educational programs, resulting from the state of the physical resources and flow and distribution of patients?
• How are issues in the medical schools relating to the distribution of primary care physicians/specialists being resolved? How is this affecting the quality of residency education?
• How are issues of multidisciplinary training being addressed at each site?
• Are there issues and suggestions about health sciences education that should be brought to the attention of the OP and Regents in the near future regarding the adequacy of teaching resources?

Naturally, all of these questions could not be thoroughly addressed with all programs at the various sites; but they did inform the questions which were posed at our visits. The committee felt that there was a remarkable sense of candor in answering our concerns by most of those who we interviewed. This exercise gave us an overview of what issues were of major concern to health sciences educators.

III. MISSION AND VALUE STATEMENTS

Any survey of the state of the health sciences education programs must start with an understanding of the mission of the enterprise and the core values that inform them. At the plenary session, which established the rationale for the formation of the committee, it was proposed that:

The mission of the University of California with regard to health sciences is to provide excellence of leadership in education, research and health care delivery. In order to achieve this mission, it is necessary for the UC faculty -to be sensitive to issues of health-care resources and societal needs. It should enable interdisciplinary linkages with existing resources throughout the University and the community, to insure the maximization of the public's health. The University health sciences programs must also insure that health sciences education and will be informed by research. There must not only be a concern about the proper preparation for practice, but for the continuance of health sciences education over the lifetime of its graduates.

A central theme for our committee work has been the attempt to determine if UC health sciences education programs can work cooperatively to better fulfill the University mission. We have asked whether such cooperation can enhance the quality of health care education, making it more available in a more efficient, effective and economical manner. We have asked what are the drawbacks and hindrances within the UC system that would potentially make such collaboration difficult to achieve. Are there strategies which can improve the sharing of curricula, technology and clinical and research opportunities within our system? Also, how can involvement of the health sciences within the Universitywide Academic Senate promote such cooperation? In what arenas would such sharing be most feasible in the near future? What level of Senate administrative support would be needed to bring this about?

To ensure that the core educational mission is successfully realized, all the health sciences programs must embody a core of values, which define its commitments to education. The committee saw as one of its initial tasks, the delineation of such values that were common to all of our programs. We wished to discover whether these values were indeed embodied in the programs, which we reviewed, particularly when e g the impact of market driven forces on clinical teaching.

Below is a critical list of educational values, which the Committee developed. Certainly this list can be modified, but we believe it was a good anchor of common agreement by which we could assess current and proposed activities within the system:

1. A strong basic science foundation to the practice of medicine and other health professions.
2. High competency in basic clinical skills.
3. Adoption of lifelong self-learning and self-assessment skills.
4. Compassion for patients, irrespective of age, gender, ethnicity, or socioeconomic status.
5. High ethical standards throughout school and beyond.
6. Strong communication skills, interpersonal and electronic.
7. Commitment to promotion of health and prevention of disease within a population and outcome based context.
8. Functional awareness of health care systems, their evolution and their resource limitations, while maintaining the capacity to transcend any system for the ultimate benefit of the patient.
9. An ability to understand and work within multidisciplinary, integrative health care settings.
10. Health sciences education setting should instill an appreciation of the best aspects of humanism, science and technology in the approach to patient care.
11. The educational process should create respect for scholarship and creative research in the advancement of the health sciences.

IV. WORK OF THE COMMITTEE

1. RESPONSE TO THE REPORT OF THE UNIVERSITY OF CALIFORNIA COMMISSION ON THE FUTURE OF MEDICAL EDUCATION

The President of the University appointed a prestigious Commission to review the current state of medical education and to make a series of critiques and suggestions for future change based on its diagnosis of current trends and problems in academic medicine. The University Committee on Health Sciences Education was asked (among other groups) to review and comment on this report. After serious consideration of University of California Commission on the Future of Medical Education Final Report July 1997, the committee wrote an evaluation which was presented to the Academic Council and included in the report from the Academic Council to the President. The complete report is appended to this document Briefly, the Commission suggested that academic centers should retool their management structure, curriculum and clinical teaching sites in such a manner as to bring them in closer alignment with the practices and demands of market driven health organizations.

Our committee felt that the Commission report portrays an accurate picture of the current state of affairs in medicine and in academic medical centers. It is correct in its belief that change is inevitable and that all assumptions about the current state of medical education should be closely examined. It relies, however, too heavily on the "Managed Care Model" of health delivery without describing how it would preserve the unique contributions of the University to scientific research and innovative clinical care. It does accurately indicate that greater efforts must be made within the whole UC system to pool resources and solve common educational problems. This is exactly the task that the current Academic Senate Health Sciences Education Committee is attempting to address. The most important ingredient in making necessary changes will be new resources devoted to innovating and implementing educational change. Teaching must be taken seriously as a valued skill. Our University should lead the nation in not only what we teach, but also how we present the health sciences to students. We should pool our resources as a system to make health sciences education itself a valued subject for study. UC can be a leader in research scholarship and teaching about innovations in health sciences education.

Our committee concluded that the Commission report ultimately did not provide either a coherent blueprint or set of prioritizations to direct future curricular change. The report is like a set of meditative exercises on the desired excellent life of AMCS. How to make such meditations into a living reality for the next century is a vital task for the faculty, deans, students and the Academic Senate.

1. REVIEW OF HEALTH SCIENCES PROGRAMS ACROSS THE SYSTEM

The committee has visited health sciences programs on the various campuses including:

• University of California Irvine (College of Medicine)
• University of California Berkeley (School of Public Health, School of Optometry)
• University of California Davis (School of Medicine, School of Veterinary Medicine)
• University of California San Diego (School of Medicine)
• University of California Los Angeles (School of Medicine)
• University of California San Francisco (School of Medicine)

Because of time constraints, several of the other health sciences programs were not interviewed during this past academic year; we hope to complete this survey in the future.

V. WHAT DID WE FIND?

A. THE STATE OF THE SYSTEM

During our visits, we found faculty and students who were eager to share their perceptions with us and who were bright, articulate and highly motivated people. By and large, they told us what they perceived to be right and troublesome in the system. We were all struck with their candor with the committee, who were essentially a group of strangers. The students were all advocates for their schools and felt that they were receiving an exceptional education, despite a number of complaints. The faculty went into more depth concerning how certain things could be improved. They were concerned about the following issues:

1. There was strong complaint about the lack of funding and attention paid to clinical teaching throughout the system. We heard that many bright faculty were leaving the UC system because of the pressures placed on them for clinical productivity in a market driven system that did not value their educational efforts with students. Clinicians often felt undervalued by their research-oriented peers and felt that there were financial disincentives for time spent with students. We asked one education dean what he would do if he suddenly were given a grant of two million dollars. He said, "Buy out more clinical teaching time." In more heavily managed care oriented clinical placements, students were perceived as distractions to the job of seeing as many people in a given number of hours as possible. At times, faculty- would threaten administrators with refusal to teach fundamental skills. "I will not take time to teach students how to read EKGS." There was a perception in at least one school that: "Faculty are not recruited because there is a teaching need in a particular area; faculty are recruited because of income that will be generated by them." The retention of clinical faculty who are recruited is seen as being based on per hour/per patient productivity. Many faculty voiced the opinion that time spent working on educationally sound improvements will actually penalize the faculty. There was a fairly general concern that FTE money was going to biomedical researchers. Clinical teaching has been carried out by faculty who do not have FTE. There was a perception that when In-Residency Clinical Faculty leave, they are not likely to be replaced. The question was asked, "how can medical student teaching be protected over the next decade?" A response was to dedicate a number of FTE to teaching faculty and allow them to be promoted on the basis of their teaching.
2. Another concern voiced was the fact that clinical faculty are being paid at primary care levels regardless of their discipline. This is so even though it is generally perceived that a surgeon who spends time teaching may actually lose more revenue than a pediatrician spending the same amount of time. There appeared to be a consensus that in the UC system at present we are in an educational holding pattern because we have sufficient resources to maintain but not to improve clinical teaching. Faculty were united in the belief that systems must be established wherein teaching is rewarded with academic prestige and incentives. There must be an effort to reduce the stresses that exist within clinical academia in order to maintain quality of education.

B. THE ROLE OF THE ACADEMIC MEDICAL CENTER IN A MARKET-DRIVEN ECONOMY

The impact of the 'marketplace' on the organization and function of Academic Medical Centers was a motif that ran through all of our discussions throughout the system. Traditionally, the Academic Medical Center has been the centerpiece of education, centralizing patient care, clinical teaching and research. Faculty were present in a critical mass to interact with each other concerning patient care and research. An important synergy was created which catalyzed medical innovation, created a sense of collegiality and provided students with visible exemplars of the highest standards of the profession. The viability of these AMCs was dependent upon a fee for service payment system and generous federal support for and research. Much of the training at these sites was centered around in-patient units with a heavy emphasis on tertiary patient care. The system was also reliant on the extensive use of technology and the presence of many highly compensated specialists. The residency programs were weighted towards specialty and subspecialty recruitment. This system provided an outstanding level of patient care but was also very expensive. The exposure of medical students and residents to outpatient settings was limited as was their opportunities to be responsible for the continuity of patient care. The exploding burden of health care costs on American business brought about demands for radical changes in the nature of care delivery. The rise of HMOs and Managed Care Plans promised a means of reducing costs and providing more efficient care of populations of patients. These approaches sought to limit the use of expensive test and procedures and provide gatekeepers to control patient access to specialists. They promised to emphasize better preventative methods of avoiding certain illnesses and promoting earlier detection of disease. Important in this approach was 'Protocol' driven treatment plans, indexing for efficiency of physicians and containment of medication costs. A critical component of these new forms of care delivery was the use of capitated treatment contracts with hospitals and physician groups.

All of these changes had profound impact on AMCs. Profitable institutions began to lose patient populations to less costly competitors and saw their financial reserves drop. In response to these new developments, AMCs throughout the UC system began to develop new strategies to adapt to this new environment. Some centers bought out primary care practices; others formed new alliances with community hospitals and, in one instance, a center merged with a non-University AMC. These moves have had a variable profile of success and it is too early to determine whether they will solve the financial and patient base problems engendered by these radical changes in medical economics. These series of mergers and acquisitions were clearly intended to protect the financial viability of the medical centers and to insure a viable patient base for teaching and research.

Often these changes were instituted rapidly, at times without complete discussion and accord with the majority of the faculty. It was believed that the times necessitated flexibility and rapidity of decision in order to compete successfully with nimble institutions not burdened with heavy research and educational demands. These events have brought about profound changes in the organization and functions of AMCs.

1. There has been a shift in clinical emphasis from inpatient to outpatient settings. There has been a drop in average inpatient stays.
2. There has been a shift away from specialty oriented residency programs toward care. (Family Practice, General Internal Medicine, Pediatrics).
3. Medical students are being increasingly trained at affiliated hospitals dispersed over wide geographic distances. There is less day-to-day oversight by FTE faculty of their clinical experiences and often a diversity of priorities and quality at these sites. Frequently, the time available for patient work-ups and teaching of students has fallen. Thus, there often is an unevenness of clinical experience depending on the nature of the affiliated site. However, this diversity also helps secure a reasonable sized patient base. Often, full-time faculty do not follow students to community sites for teaching.
4. Different clinical sites may have different expectations and controls for clinical research taking place in their institutions.
5. There have been questions raised as to whether University AMCs are fiscally untenable and whether more clinical teaching should be farmed out to more affiliated institutions who would assume responsibility for stipends and attending salaries.

It is impossible in this report to evaluate the myriad of changes that these transitions catalyzed. It is clear from talking to different faculty members that there is a wish for a greater oversight role for the Senate, to periodically assess the academic impact of these transformations. There is concern that decisions could be made about the organization and function of AMCs that would be driven by economic rather than academic concerns. Even though these changes are being made in the 'interest' of education and research, there are few mechanisms in place to assess how these domains are affected. There is a strong desire for Academic Senate input regarding major decisions that will affect faculty and students. This includes election of Senate faculty members to standing committee and governing bodies of the AMCs. Faculty recognize that the potential academic effect of some major change should be assessed before it is instituted.

C. ISSUES IN THE RECRUITMENT AND ADMISSION OF HEALTH SCIENCES STUDENTS

The UC health sciences programs have consistently been among the most sought after among applicants in the country. UC medical students have high GPA and MCAT scores and do well in securing excellent residencies. This is also true of the other clinical health sciences programs in the system. In the past, we have been very successful in recruiting minority members of our classes who have equally distinguished records. However, in our discussions with health sciences educators, we have found that they consider a most serious question to be whether UC can graduate a diverse population of physicians (and other clinicians) to serve the State of California. To underline this problem, it appears that at UCI there will be no black students in next fall's entering class, and none are wait listed. (This was true at UCSD as well). Underrepresented minorities tend to be highly represented in primary care settings in disproportionate numbers. They serve their own communities and serve as role models to younger students. Since recent regental decisions concerning affirmative action have been in place (SP-1 and SP-2), there is grave, concern that UC will not be perceived as a welcoming environment for minority students. Diversity rather than affirmative action is seen as the key issue. Diversity is an essential component of the student body. That body should be reflective of the population of the State as a whole. It is important for students to understand how health care is approached among various ethnic communities. The University is obliged to provide health care professionals who will serve underserved populations. There were several suggestions made as how to ensure greater diversity in UC entering classes. Among them were:

1. Provide more scholarship money and other forms of financial aid (loan forgiveness) for those students who come from disadvantaged backgrounds and those who would serve in underserved communities. Such assistance would help in recruitment of a more diverse student body.
2. Is the faculty representative of minority groups? Minority faculty serve as a role model for all students, but particularly make minority students feel more secure in a health sciences setting. As we move from the "Great White Tower" of medical centers into outpatient centers, our students encounter more minority patients and more minority clinicians taking care of them.
3. There are many more cross-cultural elements introduced into health sciences curricula which acknowledge the special needs and sensitivities of minority populations. Schools like UCSD-SOM have initiated various exchange programs in Tijuana, Mexico, to give students a better exposure to cultural differences.
4. A creative suggestion for approaching this problem of increasing our applicant pool (including minority and disadvantaged candidates) emerged from one of our meetings. This solution would be to create a centralized UC admissions system with shared resources across the five medical schools. Such a system would cut down on the time and expense of applying to individual schools, and provide in one packet information about the resources and advantages of each of the campuses. Such a unified system could coordinate outreach programs to secondary schools throughout the state to help students think about a health career and assist in college and medical school planning. Such a system could follow students through high school and college and help them to more successfully prepare as candidates for admission. At UCI, 5 to 6 programs were operated a year, helping high school students in a variety of settings. These were funded by grants, but we were told that, since passage of SP-1, granting agencies are not as keen to provide funds to UC. This is a significant problem that will affect not only minority students, but all students at the University, depriving them of vital peer learning opportunities. Many of our state's citizens will be woefully underserved if the University cannot find creative solutions to this problem.

The University Medical School Programs continue to attract a very large number of academically talented students who bring a variety of academic, research- and community-based skills to these programs. We hear from the Dean of Admissions that the increase in tuition has not affected the choice of UC campuses by applicants, yet the students felt that there was a line (not far from the current costs) that might alter student decisions to come to UC. Clearly, this would impact more strongly on minority and economically disadvantaged students. It would be prudent to survey on a yearly basis the economic make-up of our collective student bodies to determine whether the rise in tuition is affecting either the demography or quality of those who choose UC programs. Similar conclusions regarding the high quality of students and success in recruitment hold true for all the other UC health sciences programs. We are doing very well in recruitment but there are many factors which require vigilance and policy review, particularly with regard to the diversity of our classes.

D. STUDENT COMMENTS CONCERNING THEIR EDUCATION

During every visit to a health sciences program, we spoke to a group of students representing each of the various classes. The size of the group varied between 5 and 8 per visit. Naturally, this was not a carefully picked statistical sample of the student bodies. However, several themes emerged from all of our interviews. A comment from one student in the School of Optometry was typical of the other groups. 'It would make a better program to start integrating students earlier from thinking purely didactically, to thinking about case histories, differential diagnoses, problem-solving orientation and the broader picture of patient care." Students, regardless of their discipline, feel that they can better integrate information if R is reinforced with direct patient contact early in their education. There is gravitation towards 'active learning' as opposed to more traditional lectures, and early exposure to real clinical situations seems a way of engaging their attention and reinforcing the principles of health care. Most of our programs are working--on coordinating and integrating clinical learning with the basic sciences in a very successful manner. More cross-campus discussion about how this is best accomplished would be welcome throughout the educational programs.

Listed below are some of the student comments:

1. Students do not like lectures where they are given a list of informational points rather than deriving general principles. Once they begin clinical rotations, the application of principles becomes more real and important to them.
2. Students feel that the amount and pace of information expected to be learned in two years is 'inhuman' but cannot imagine how it would be possible to learn at a more leisurely pace in that given amount of time. Most students do not wish to extend the required length of professional education. They do feel, however, that a great deal of information taught in lectures should concentrate on a smaller number of critical points, supplemented by readings. It would be useful to provide more slides on laser disk, more three-dimensional holograms which present visual information in a way that students can better understand and visualize.
3. Students complained that there is not enough time given in the curriculum emphasizing preventative medicine, which they view as very important. This is despite the importance placed on this area by managed care practices and HMOs. There was insufficient teaching about this issue both in the basic courses and, especially, on the wards and clinics.
4. With the greater emphasis on outpatient clinical teaching, there is a perceived need for greater coordination in teaching methods and goals across the various teachers. Students perceive that there is often an inconsistency and variability of what they are taught by various clinical mentors. Although they appreciate the opportunity to get out into the 'field', they would like greater clinical curricular oversight by course directors.
5. Another interesting commentary from a medical student is that there should be a greater emphasis on developing fitness programs for students and house staff. It is observed that students often operate under sleep deprivation, eat junk food, drink too much coffee, and in other activities deleterious to their health. Emphasis on the physical and mental well being of students is essential to their success embarkation on a health career and facilitates their ability to serve as role models for their patients.
6. It was our perception that our student body continues to be drawn from intelligent people who are enthusiastic and highly motivated to become health professionals. Unlike many of their older mentors, they are not daunted by the current trends in the market driven forces. They take a realistic stance that this is how the field is at present. They want to learn about cost conscious medicine and master its requirements, but they are not convinced that current practice is always in the best interest of their patients. It is very important for these students to be able to practice as skilled problem solvers and decision-makers. They perceive the threat to these attributes, as current care systems take on a more corporate identity with standardization of practice. They do not wish to become interchangeable components in a more 'rationalized' system. Our present success in attracting highly skilled and creative students to our programs may change if students believe that the environment of practice is disco professional initiative and personal decision making. The field of health care education presents a paradox to be solved; how do we continue to draw upon exceptional people to become the researchers and practitioners of the future as we move toward more standardized domains of practice that do not always reward clinical innovation?

E. GRADUATE PROGRAMS

The University, as part of its health sciences education programs, sponsors a number of graduate degree options. As a University system, we are one of the most highly regarded sources of producing well trained, creative graduate students who go on to receive Ph.D. degrees, and serve as faculty members at highly prestigious academic and private corporate institutions. We do exceptionally well in competing with world famous private universities (e.g., Harvard, Stanford, and Yale) for enrolling very promising students. This is despite the fact that the private universities can offer much higher and more consistent stipends to these students than can UC. Because of NIH regulations, students cannot receive federal monies until they are established with a research mentor and laboratory. This is not possible in the first year of enrollment. It is, thus, very difficult for the UC system to come up with competitive stipends for the first year of Ph.D. funding in the biomedical sciences. Some universities (e.g., UCLA) have developed imaginative programs such as the ACCESS arrangement to fund these positions. Others (e.g., UCSD) struggle to find funds, though they continue to attract students of the highest caliber.

This is a serious issue for the University as a whole. These students are absolutely vital to the health and continuity of our highly regarded graduate programs. These programs make an enormous contribution to the reputation of our health sciences programs, are vital to carrying out 'cutting edge' research and help to bring research funding into our programs. Yet, there does not appear to be a systemwide approach to stabilizing this problem. It is urgently important that we continue to get the best and brightest of these future researchers if we are to maintain our status as leaders in the biomedical, epidemiological, social-behavioral and clinical research domains. The university must view these students as a vital component to our reputation for excellence. We cannot rely on past performances as an indicator that we will continue to successfully compete. It is a testimony to the excellence of our research faculty that the students chose to come to UC programs despite often lower stipend support. The faculties at all institutions have been creative in devising means of continuing the flow of student support. Yet, this is an arena that warrants the attention of the Senate as a whole.

A similar statement can be made concerning the recruitment and support for the M.D./Ph.D. programs throughout our system. They, too, often function at the economic competitive disadvantage to other private institutions; and yet they are a source of great research productivity and c distinction. Our committee has not yet reviewed the situation concerning graduate degrees in other professional programs; however, we anticipate that they operate under similar financial strictures.

F. CURRICULAR ISSUES

The past several years have seen a remarkable re-examination of the medical student curriculum throughout the UC system. Past assumptions about the way in which basic sciences and clinical medicine should be taught, have been challenged, with the result that new and innovations have been introduced into the course of study. In addition, the sphere of knowledge and skills required of today's physicians has exploded, with new subject content being added to the educational experience.

The emphasis has been away from the passive mode of learning toward more active Problem-solving experiences. Students are encouraged to take more responsibility for how and what they learn in order to achieve a greater personal involvement in their acquisition of knowledge, skills and attitudes. Learning at this stage of their careers is seen as just the first step in a lifelong commitment to their future education. The changes have emphasized fewer large lecture sessions and a greater use of small group teaching. There has been experimentation with uses of computers for a wide variety of learning exercises which range from teaching pathology to clinical case management. Computers have also been used to expedite library searches and the system is moving toward a digital library. Clinical examinations have used simulated patients for both physical/diagnostic exams, as well as learning interviewing techniques. Binding all these threads together is a greater appreciation of how adults learn and retain and use information.

It was the committee's impression that medical school faculty and particularly the Deans of Curriculum are paying more attention to current research and g about adult learning. It is not just important to concentrate on what we teach, but equally critical to understand how we teach. Understanding what kinds of skills and information are best assimilated and used, and by what forms of presentation, is becoming increasingly vital in health sciences education as the scope of what our students need to know expands. Later in this report, we append a document outlining the need for a systemwide Institute for Health Sciences Education that would coordinate new learning and techniques among all programs.

Beyond the techniques for learning, there is also general agreement that the knowledge and skill domains of health sciences students must be expanded to include:

1. culture competence in understanding our patients from difference ethnic, racial and religious backgrounds;
2. appropriate use of computers and information systems in modem medicine;
3. exposure to population-based approaches to medical practice, including contemporary epidemiological research techniques;
4. awareness of major issues in medical economics and the role of the marketplace in health care delivery systems;
5. appreciation of the dynamic interaction between biomedical and psychosocial factors in the instigation, course and recovery from illness;
6. understanding of current approaches to prevention of disease in health practice;
7. knowledge of and sensitivity to ethical issues in health practice;
8. appreciation of the roles of religion and spirituality in contemporary practice.

Perhaps the most important curricular change has been the greater emphasis on primary care education that brings together a number of departments to teach skills fundamental to the basic care of patients. These changes are exemplified by such courses as the DOCTORING CURRICULUM at UCLA or the GENERALIST CURRICULUM at UCSF. These and other integrative curricula are intended to teach our students both the art as well as the science of being a physician. They deal with basic examination skills, psychosocial approaches to the patient, ethical concerns, and improved communicational skills, among other topics. These courses attempt to create more humane physicians who are still grounded in the science of medicine and will prepare them to deal with patients who are becoming more knowledgeably involved with their own care.

These are but a sampling of the new issues and content which are becoming incorporated into the curricula of the health sciences. This list does not include the rapid expansion of knowledge in the purely biological domains of knowledge, which the student must master. Clearly, new choices must be made about how the curriculum must be organized to accommodate these new arenas of skills and knowledge. What must be reduced or eliminated to accommodate new courses? How much direct didactic teaching must be provided and how much do we want to depend upon new technologies for self-learning? What are the appropriate roles for the faculty to play in this new environment of learning? How much is innovation in teaching to be rewarded in the UC system, which has put a premium for faculty advancement on clinical and basic research?

These are searching questions, which the individual programs as well as the Academic Senate must address in the future. We have been impressed by the initiative that the Schools and Programs have taken to look at traditional g paradigms and change them. Our committee believes that UC can become a national leader in the sphere of the health sciences and pedagogy of health sciences education.

G. GRADUATE MEDICAL PROGRAMS

We have seen how medical student education is being revolutionized by new learning initiatives and content areas. Graduate medical education throughout our system has also undergone important changes during the recent past. Most important has been the Memorandum of Understanding by which the President of the University of California agreed to cut the number of specialty and sub-specialty residency and fellowship programs. This agreement with the Governor was in line with the shift in policy throughout the country to meet the increasing demand for generalist physicians and to reduce the oversupply of specialists. Programs have been given a number of years to adjust to these changes by reallocating the proportions of graduate and generalist physicians trained.

Another adaptation that graduate programs must make is catalyzed by the reduction of -monies coming from governmental and other sources to support them. The Balanced Budget Act alters the revenue flow from Medicare to support residency positions. The impact of market forces as exemplified by the rise of Managed Care Plans and HMOs is also changing the traditional streams of revenue that have previously paid resident stipends. These alterations of revenue from both governmental and clinical sources have forced a reconsideration of what size graduate medical programs any academic institution can sustain. In several instances, the size and cost of these programs appeared larger than the revenue base which undergirds them. One can speak of monies that come from nonclinical sources as "Funds at Risk." These include Disproportionate Share revenues, State Clinical Teaching Funds, and a variety of federal sources. Thus, each medical center must carefully calibrate the size and expense of its graduate programs in relationship to a number of fiscal considerations.

In the past, there was often no coordination within an academic hospital center as to what the scope and size of a graduate program should be. Programs grew, often without any relationship to the local or national need for physicians within a given specialty. The fee-for-service system permitted residency programs to grow as long as revenues kept pace with stipends and the State 19900 funding filled in the gaps. Today, more searching questions are being asked within the system. How many specialists do the community, state and nation really need, and how are we going to pay for them?

There are those with whom we have spoken who believe that the shift to generalist and primary care g may be going too far now. Have we really good data on the number of specialists we will need in the future? Who will train the generalist in certain highly technical skills? There is doubt that the training program for primary care physicians gives them a high level of skill and knowledge that was formerly the domain of the specialist. Can the length of the g program of primary care physicians give them any more than a superficial brush with highly sophisticated diagnostic and therapeutic skills? These are questions that our system must address and struggle with in the future.

Another issue concerning graduate education is the ever-expanding set of requirements that specialty accrediting boards demand for certification. Although the academic institution is responsible for designing the medical student curriculum, it is the various Residency Review Boards nationally that set accreditation requirements. The trend has been toward multiplying the clinical and didactic expectations, which puts additional stress on balancing clinical and educational time. This becomes important when residents are also seen as a revenue-generating source for clinical services.

Questions arise as to whether all UC Medical Centers should provide the full range of specialty and sub-specialty training opportunities. It is becoming clear that this ambition may not be possible in all settings because of changes in the flow of patients to certain services, and because of an over-supply of specialist clinicians. Clearly, residents and fellows play an important role in our system, providing a stimulating environment for clinical faculty. Reducing the size and scope of graduate programs will have an impact -on many amenities of academic life that we have previously taken for granted. This is a very sensitive arena where conflicting elements of physician supply, patient flow, fiscal resources, research opportunities and satisfaction will come to bear. Yet, until the present, this has been a relatively silent area of University policy that will require more attention in the future.

H. CONTINUING EDUCATION

With the ongoing explosion of health sciences knowledge, it is impossible for any four-year curriculum and post-graduate training program to complete a student's portfolio of knowledge and skills for future practice. In the health professions learning is truly a lifelong commitment. There have been professional requirements for many years that license renewal is linked to demonstrating attendance at continuing education programs. Yet, with a few exceptions, this arena of health education has been rather ignored; stodgy and uncertain of its purposes and content. There has been comparatively little research on what health professionals need to learn to remain on the cutting edge of their field and what is the best way to present them with new material. In all of our visits to the different UC campuses, this was an almost absent item of discussion.

In the past several years, continuing education programs have mainly centered on a 'lecture' type format with comparatively little interaction between audience and presenters and rather perfunctory modes of evaluation. There is often little 'hands on' type learning or use of small groups. As attempts are made to make continuing education individuated and active, costs to participants naturally rise. There is a clear need to understand what the University's role and responsibility should be for continued education in the health sciences field. With the advent of new learning philosophies and technique for basic health education, there should be a determination of how continuing education can be delivered in a more relevant, engaging and cost-effective manner. This should involve the greater use of technology such as CD Roms and curricula geared to the needs of older and busier practitioners. Again, this is an area where a systemwide approach, bringing together our individual campus and program experience and knowledge in this arena, would be of enormous help. There is no reason why sharing of knowledge and innovation should not be cross-institution priorities for the delivery of education, research and scholarship into lifelong learning.

I. ASSESSMENT OF KNOWLEDGE AND SKILLS

As world health sciences become more complex with the addition of new knowledge, skills and techniques, the need for accurate assessment of these acquisitions increases. It is necessary to understand not only what our students know, but also how they communicate, what values they hold, and how they are able to make decisions appropriately in critical situations. In health sciences education, the pace of new knowledge and learning objectives has outpaced our ability to evaluate and assess their acquisition and application by students. This is, again an area where the UC -system -as a whole can meaningfully share experience and experimentation in this vital area of understanding what our students are capable of doing as graduate professionals. This, again, speaks to a need for a better systemwide integration and coordination of studying and developing evaluative instruments that will tell us what we are teaching well, and where we are less effective. Educators must relate across disciplines and campuses to vigorously share knowledge, do research and develop new instruments of assessment.

J. FACULTY ISSUES WITHIN THE UC SYSTEM

The University has a very diverse and outstanding faculty associated with its various health sciences programs. It is a mixture of tenured, in-residence, Professors of Clinical X, Clinical Professors, Adjunct Research and voluntary positions. Health sciences faculty perform a wide variety of functions including teaching, research direct clinical care, administration, supervision of clinical work and service on national professional and scientific bodies. Traditionally, the faculty has been organized along departmental lines, with a group of faculty responsible to the Department chair and through the Chair, the Dean and then the Chancellor. Teaching, research, clinical responsibility have all in the past been channeled through departmental routes. There is a wide departmental discretion about educational priorities and distribution of research space. For many years this system has served health sciences programs well. However, in recent times, there has been an alteration in this arrangement across the various campuses. New arrangements like the Program in Biological Sciences (UCSF) have emerged, which join the resources of several departments for the purposes of teaching and research. We have seen such 'consortium' arrangements emerging in almost every program that we have visited. The department is slowly displaced by new arrangements, which pool resources and talents. This change is only beginning and has not replaced the traditional departmental roles to a great extent. Yet, it is a portent of new alignments, which concentrate and make more efficient program resources.

This change requires new adjustments for faculty who may now have to relate to a departmental and super-departmental arrangement. These combined programs have seemingly gone very well, with a critical mass of faculty from different disciplines pooling their knowledge and efforts to plan and implement new programs. Any change is, however, stressful for some. The role of the department chair may be reconfigured in the future. Old loyalties may shift to more dynamic multidisciplinary programs. Funding may funnel into the schools (for research and teaching) in new ways. Inevitably, the definition of what a faculty member is in relationship to his department and school will shift and, with it, new conceptualizations of professional roles. It will place a greater emphasis on collaborative efforts with peers and require a broadening of academic perspectives. Whereas in the past, many faculty functioned in a highly individualistic manner, this new trend requires social skills as necessary to develop joint programs. It is uncertain how this will affect such issues such as recruitment, retention, definition of duties, promotional criteria and teaching assignments in the future. This is an evolving phenomenon that recognizes the inherent multidisciplinary nature of health sciences and may require attention and study by the system as a whole.

Another significant change that is affecting faculty is the new set of clinical arrangements being negotiated by Academic Medical Centers. As AMCs enter into negotiations with HMOs, Managed Care Plans and Governmental Agencies, the role of the faculty in providing direct clinical care in contrast to more traditional teaching and supervisory roles has been accelerated. This requires a new conceptualization of the relationship between student and clinical teacher. We have heard numerous complaints by clinical faculty that their schedule is dominated more by monetary rather than academic considerations. They are concerned that they are penalized for time spent in teaching and are often not encouraged to initiate clinical research projects. Much of this information is anecdotal at resent and needs to be confirmed by more precise data. Yet, the complaints from clinicians about the change in direction of their academic roles was ubiquitous in all of our conversations across sites. They were generally unhappy with these changes, although they understood the economic rationale for the new arrangements. There have been reports of highly respected faculty leaving the UC system because of the more constricted roles in which they have been placed. There was, again, anecdotal material about the negative effect that this was having on medical students. In one instance, an important cardiologist threatened not to teach students about reading EKGs because of severe 'time restrictions.' This is clearly not a situation that is going to promote either good clinical care or outstanding teaching.

Our Committee viewed the sense of dissatisfaction among clinical teachers as the most serious problem confronting health sciences education today. We believe that this is a national, and not solely local, phenomenon. Clinicians are asked to adjust to a bewildering array of new payer expectations both administratively and clinically, while also continuing their traditional teaching role with students. In the end, many faculty rebel against what they see as unrealistic demands by cutting back on teaching time. Whether this situation is self-adjusting or will require more centralized intervention is uncertain at present. Yet, this is an arena where the Academic Senate needs more input and information about the changing clinical teaching role and its impact on students.

Many faculty expressed to us their view of what the essential factor of a UC health sciences program should be. They believe that our programs must retain their high academic standards and productivity so that we do not become trade schools or, as one dean put it, "farm clubs for managed care companies." We are one of the world's leaders in producing outstanding biomedical scientists and research clinicians. The values of scientific inquiry are transmitted to the students whom the faculty teach in the lecture hall laboratory or clinic. Equally important, the faculty tell us, is the art of teaching students how to be ethical, communicatively sensitive clinicians who combine scientific discipline and empathic concern.

There are some critics of the present state of academic medicine who say that these standards are anachronistic and inappropriate for today's marketplace. They advocate letting the market determine what is important to teach and which values to impart to our students. One might say that Stradivarius violins are wonderful, but too costly and complex to replicate in our present world. So, too, the model of the scientist-clinician can no longer stand as an exemplar for today's students. We believe that our faculty is telling us that UC must preserve its essence of excellence, and continue its research tradition, while finding new ways of incorporating the -present realities of health- care delivery. This 'will not be easy, and certainly will not be cheap. The Senate must continue to listen to our faculty to learn how they believe such a is being The Health Sciences Education Committee can serve as a listening post for such opinions and share them with the Academic Council and the system as a whole.