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University Of California

Office Of The Vice President

Health Affairs

1111 Franklin Street
Oakland, California 94607-5200
Phone: (510) 987-9697
Fax: (510) 987-9715

January 31, 2000


Dear Colleagues:

At the request of Provost King and Academic Council Chair Coleman, I am writing to request your review of the enclosed Final Report of the Academic Senate's Health Sciences Education Committee. This report was prepared by the committee based upon information gathered during meetings and discussions with UC faculty, students and administrators at each of our health sciences schools. It is my understanding that the committee also had an opportunity to meet with many of you during the course of their two-year review.

The enclosed report contains findings regarding current issues and challenges facing our health sciences education and training programs. The report also makes specific recommendations regarding efforts and initiatives that the University might choose to undertake in the future. In this regard, I would like to draw your special attention to the recommendation concerning the possible future establishment of a systemwide Institute for Health Sciences Education.

We would appreciate receiving your comments by March I so that they can be reviewed, compiled and forwarded to Provost King and President Atkinson. Please feel free to call me at (510) 987-9697 if you have questions or need additional information.

Best regards,

Cathryn L. Nation, MD

President Atkinson
Provost King
Academic Council Chair Coleman
Professor Zegans, HSEC Chair

Interoffice Memorandum
Office of the Provost

January 14, 2000


Dear Cathryn:

I would appreciate it if you would solicit comments from appropriate sources on the attached Final Report of the Academic Senate's Health Sciences Education Committee. I would like to receive these comments no later than mid-March so I can forward them to the President and to Academic Council Chair Coleman; Larry hopes the Academic Council can discuss these reports and comments received this spring.


C. Judson King
Provost and Senior Vice President -
Academic Affairs

President Atkinson
Academic Council Chair Coleman

University Of California, Academic Senate
Berkeley Davis - Irvine - Los Angeles - Riverside -
San Diego - San Francisco - Santa Barbara - Santa Cruz

Office of the Chair
Telephone: (510) 987-0711
Fax: (510) 763-0309 1111

Assembly of the Academic Senate, Academic Council
University of California
Franklin Street, 12th Floor
Oakland, California 94607-5200


January 4, 2000

Dear Dick:

At its December 9, 1999 meeting, the Academic Council received final reports from two Senate Special Committees:

  • Division of Agriculture and Natural Resources (DANR) Workgroup
  • Health Sciences Education Committee (HSEC)

The Council's further deliberations on these important components of the University's mission should be informed by input from the campus and system administrators responsible for these areas. I would ask that you forward the reports to the Chancellors and the appropriate Vice Presidents. In your transmittal letter please ask that the reports be shared with the relevant Vice Chancellors, Deans, and Directors.

To keep our momentum going on these topics, I would like to bring the reports back to the Council in the spring. It would be most helpful if the campus and the UCOP comments were forwarded to me by April 1.


Lawrence B. Coleman, Chair

Encl: 2
Academic Council
C. Jud King, Senior President and Provost, Academic Affairs
William Sirignano, Chair DANR Work Group
Len Zegans, Chair HSEC
DANR Workgroup Analyst B. Marton
HSEC Analyst L. Tapley Van-Pelt.

The HSEC has met for the past two years to study issues and problems at all of our Health Sciences Education Programs covering each of our University Campuses. We interviewed Deans, Administrators, Students, Regular Faculty, Clinical Faculty, and Graduate Students in an effort to understand the state of the system as well as identify unique issues affecting specific programs. The Committee included representatives from each program as well as special representatives from key Academic Senate Committees. Each separate program was visited on its home campus in order to maximize the number of relevant people interviewed and get a better sense of the facilities and local context of instruction. Following all of our visits and interviews the HSEC members met in a day-long executive session to outline the most important issues that we encountered, pose potential solutions to some of these problems and to make recommendations for the future activity of the Committee itself. Highlighted below are the major finders of our two-year-long activity. The issues outlined are dealt with in more detail in the two separate reports covering the years 1997-1998 and 1998-1999.

  1. All of our Health Sciences Programs have achieved top national rankings in terms of the breadth of their research portfolios, success in competing for research grants, quality of faculty and the ability to attract for admission outstanding students. However, this exemplary success masks the strain on the faculty who are making things fine by exceeding accountability expectations through their extraordinary commitment and loyalty.
  2. The most striking finding that the HSEC uncovered was the profound sense of frustration by many of the faculty concerning the lack of or loss of resources. This includes FTE positions, decline of clinical clerkship sites, deterioration of classroom and laboratory facilities and loss of clinical teachers.
  3. Relating to #2, it was felt throughout the system that there are insufficient numbers of junior ladder rank faculty in the tenure track and also inadequate numbers of junior faculty in clinical series in several departments. Over the past ten years, there has been a trend to increasing dependence on volunteer faculty. However, both their numbers and interest in continuing to engage in volunteer teaching and training have been declining recently. The Committee believes that, in every school that it has visited, FTE cuts have led to declines in educational content and the ability of the institution to meet its commitments. This represents a threat to patient care and the compromise of education. There is a need to reassess this situation with a view to augment FTE allocation to each department where shortages are negatively impacted on their clinical and teaching missions.
  4. Faculty advancement/CAP issues. The Committee heard from various faculty members that there was an overemphasis on traditional research activity in supporting promotion and that there should be a broadening of the definition of scholarship and scholarly work with respect to 'promotable' activity. Scholarship can be viewed as discovering new knowledge and communicating it by innovative teaching methods. We learned that many faculty feel that previously, the criteria for scholarly activity by clinical teaching faculty has not been documented in realistic terms that faculty can readily understand. Patient care and teaching in clinical settings needs to play a more substantial role in advancement evaluation. Scholarship should be seen as innovative contributions in a variety of venues and not solely based on peer-oriented articles in selected journals. The Committee believes that there needs to be a renewed dialogue with the Academic Senate, Committees on Academic Personnel (CAPS) and campus leadership concerning the process and criteria for promotion within the Health Sciences. The question was raised, but not resolved, whether there should be separate CAPs for the Health Sciences on general campuses.
  5. Professional Fees: Each of the programs that we visited maintained that these fees were a critically important source of funding for different aspects of their programs, supporting program growth and stability. Several faculty members advanced the idea that 'desegregating' professional fees from general fees would support the financial viability of their programs. It was recognized that this was a politically charged issue at the present time. It was argued that because there is a current freeze on all student fees, that professional fees should be permitted to rise to their previously prescribed level in order to alleviate financial pressures on program development and clinical teaching. Earlier, long-term program budget plans were made with the expectation of professional fee increases. Our members acknowledge that UC still offers a bargain in terms of health sciences education compared to private institutions, but that consideration should be given to the idea of unfreezing professional fees.
  6. Meeting increasing financial Pressures: In light of our discussion concerning professional fees and the pervasive decline of Health Science programmatic resources, the Committee recommends that:
    1. there is a need for a new infusion of additional State 19900 monies to support health sciences programs, particularly where 'at risk' funding for education may be severely reduced;
    2. a reconsideration of professional fees should take place so that each program may reach its original prescribed upper level; and
    3. as part of a fiscal package of restoring the fiscal health of health sciences education, programs should receive a more adequate return of research overhead that their schools or departments generate. However, the Committee cautions against succumbing to pressure to overly rely on subsidizing clinical education activities with research funds. This is a complex issue involving issues of equity among programs within and between campuses. Yet, the overhead question was a ubiquitous issue raised among the Health Sciences Programs to meet resource shortages and provide investigators with added incentive for grant applications.
  7. There is an impending crisis within our System, touching on the provision of adequate clerkship sites for clinical training, particularly in dentistry, nursing and pharmacy. Our programs are being competitively bid out of the market for clinical training sites in the community by private degree programs. There are several other reasons why clerkship sites are proving insufficient at present for our student needs. Volunteer faculty at these sites are being asked to see more patients to raise their own productivity. This cuts into the number of patients that the students can see. Some clinical teaching staff are told by providers not to see MediCal patients because they are not subsidized. Shortened hospital stays and emphasis on ambulatory care have impacted on clinical training sites at Academic Medical Centers. Because available clinic space is needed by UC faculty to generate revenues, students are often sent to off-site clinics where there may be inadequate supervision or patient flow.
  8. Recruitment and Retention of Faculty: During our visits to the various schools and programs, we have heard many stories of faculty disappointment with their current activity as teachers and supervisors. This was most marked in the 'arena of clinical teaching. The concerns centered on 'increasing demands for revenue generation, less time allocated for interaction with students, and loss of financial and physical resources in their departments. This trend was especially true in the non-MD schools, where there is a sense that faculty are working far beyond expectations just to maintain (not advance) the quality of instruction. There is a feeling that their efforts are often not recognized and appreciated and that a number of valuable faculty colleagues are leaving their academic posts. There is a sense that their situation has been ignored at higher levels of the University and it has only been the HSEC that has spent time visiting them and learning of their issues and disappointments. It has been impossible for our Committee to quantify what has been the actual loss of teachers both in numbers and in years of experience. If these anecdotal reports are true, it represents a serious threat to our entire health education system and must be better understood and rectified. A beginning of this process would require some centralized survey of the movement of regular and volunteer faculty in leaving the system and some qualitative estimate from program directors concerning its impact on education. The office of the Vice President for Health Affairs might best conduct such a survey.
  9. The committee strongly endorsed the role of the Office of Vice President for Health Affairs: It was noted that Vice President Hopper had announced his retirement and that a search for a replacement would soon be initiated. The Committee was supportive of the many contributions that Vice President Hopper had made to the academic missions of the Health Sciences. We also believed that in the future it would be important to build on his legacy and for that Office to take a more proactive stance in periodically visiting the various programs and learning more intimately of their visions, problems, and achievements. The impact of such visits by an OP representative for the Health Sciences Programs would help decrease their sense of isolation and provide a forum for problem resolution. It was felt that the Health Affairs Office should not only respond to external requests for information and policy analysis, but also take initiatives to initiate new ideas and programs to keep UC at the forefront of innovation in Health Education.
  10. ESTABLISHMENT OF A HEALTH SCIENCES INSTITUTE: One instance of such an initiative was the cooperation of the Office of Health Affairs with our Committee and the Academic Council, in exploring our suggestion for developing a UC System-wide Institute for Health Sciences Education. The proposal to develop such an Institute arose from mutual recognition among all the programs that the growing complexity of the educational responsibilities within the Health Sciences required innovative new approaches to curriculum development, communication of knowledge and sharing of education expertise. With regard to education of health sciences students, the traditional approach of 'each tub on its own bottom' is not adaptive in the present fiscal and knowledge environment of our fields. All of the programs which we visited voiced the wish for greater collaboration and integration among the various schools and programs educating health sciences students. The Committee believes that such collaboration can best be achieved by thinking of the Health Sciences as a more integrated educational network within the UC System, where contributing programs pool their imagination and intellectual resources. A Health Sciences Institute would respect the particular unique role that each school and program plays on its home campus and locality. It would, however, provide a flexible and focused home for meaningful inter-school and cross-campus collaboration. This concept would need to evolve over time with considerable input from faculty, students, deans, and administrators. The Institute and its projected roles are described more fully in the body of this report.
  11. SUBCOMMITTEE ON CLINICAL TEACHING: During the course of the past year, two subcommittees were established by the HSEC to look more closely at two vital issues in current health education. One was the formation of a committee under the leadership of Dr. Peter Wagner on Clinical Teaching. Dr. Wagner has prepared a document to send out to clinical educators asking for suggestions on strategies for relieving the problems related to clinical teaching. One problem is maintaining clinical practice sites of clerkships--the sites themselves, where students are welcomed. The other is maintaining faculty in a fashion where they have sufficient time to teach. The HSEC felt that clinicians on the front line who wrestle with problems of clinical teaching would be in the best position to judge what strategies for preserving excellence should be tried. It was our perception, as discussed above, that there is currently a lack of resources to pay for clinical teaching sites in some programs and less time available to clinical teachers to spend with students. The committee endorsed the idea that there is no substitute for in-depth teaching of students who are learning basic skills. Our group believes that there is not sufficient awareness at the highest levels in the University and the State of the dire straits of many of our clinical programs. It is an issue of ensuring the highest quality clinical care for the citizens of California. The Health Sciences teachers are telling us that we cannot run the system as a quality enterprise with the number of sites available and the faculty time available. The Subcommittee on clinical teaching will attempt to both qualitatively and quantitatively document the needs and the strengths of the present system. It should have its report complete at some point in the next academic year (I 999/2000).
  12. SUBCOMMITTEE ON EVALUATION: Dr. Constance Bowe chaired this subcommittee. This group is looking at the best ways to develop criteria for assessing the criteria for the evaluation of courses, curriculum, and teaching. The Chair recommended that the committee look into the process of how faculty are assessed for promotion and determine how teaching can play a greater role in that process. Another direction that this group might take is evaluating how we do in teaching values, attitudes and beliefs to students, and learning how well these traits are maintained throughout undergraduate professional training, postgraduate years and into practice. We might study how teachers most significantly influence students' ideas about appropriate professional behavior and values throughout their training. How do role models and exemplars affect student attitudes toward their profession? And do these exemplars feel that the educational system gives them the resources and time to be available to students. The subcommittee will report on its work in 1999/2000.


  1. It is essential that the work of the HSEC continue into the future (preferably as a Standing Committee of the Academic Council). The furious pace of change in the Health Professions and the many financial pressures on Health Education, requires that the quality and stability and innovative capacity of our programs be continuously monitored by the Academic Senate of UC. There is no other committee that does or can perform this task. The sheer size of our Health Programs, and their intrinsic complexity, calls for a single committee devoted to continuously monitoring their progress, problems, and needs for change. If the HSEC is dissolved, there will be no other Senate group that can comprehensively perform this task. An omnibus committee on professional schools (if one existed), would be overwhelmed by the scope of their task and lack the common base of experience in the Health Sciences, which our committee possessed. The maintenance of quality programs in the Health Sciences devoted to teaching, clinical care, and basic and applied research, are vital to the well being of the citizens of our state. We believe that there are serious problems despite the excellence of each other's programs, which requires systematic review, evaluation, and creative problem solving. A good beginning has been made by the HSEC and it should be encouraged.
  2. The Vice President for Health Affairs, in collaboration with the HSEC and Academic Council, should begin a thorough investigation of the problems in securing and maintaining Clinical Clerkship sites throughout our Professional Training Programs. Issues to be addressed would be determining whether financial considerations are making us noncompetitive in securing and maintaining clerkship sites and whether sufficient on-site teaching is available.
  3. An INSTITUTE FOR HEALTH SCIENCES EDUCATION, should be established through the Office of the Vice President for Health Affairs to:
    1. Help develop new curriculum tools and designs to be shared across the Health Education Programs and study and develop new methods of teaching.
    2. Design state-of-the-art tools for evaluating students, faculty, and courses. High precision tools for carrying out such evaluations should be developed and shared throughout the system, which the Institute could initiate and implement.
    3. Play a leading role in the assessment and development of learning technology. The Institute can play a major role in exploring national and worldwide trends in educational technology and developing new technologies for VW in Health Sciences Programs.
    4. The Institute can study the processes of lifelong learning, whereby health scientists can retain and broaden their professional knowledge base and skills. We must discover whether patterns learned early in professional g can be altered to accommodate new knowledge about research and practice patterns.
    5. The Institute can play a leading role in providing important linkages between evolving changes in Public Policy and opportunities and problems in Health Education.
  4. It is critical to collect up-to-date data on the status of the current cadre of clinical teachers within the system (ladder rank, in-residence, clinical X series, and volunteer series). This is necessary to document whether the number of clinical teachers is adequate for the number of students and their clinical assignments. It is also vital to document whether the number of clerkship teaching sites is adequate for the training of our Health Sciences undergraduates. A survey is needed to both quantify the adequacy of teachers and teaching sites as well as to gain an estimate of the experiential quality of our teachers. This is particularly true for the Schools of Dentistry and Nursing (but for Schools of Medicine as well). Such data collection can be organized through the Office of Health Sciences Affairs. In brief, is there a good match between the numbers of students who we are obligated to train clinically and the teaching and site resources available?
  5. During the course of our visits, there was an undercurrent of concern that there has been a decline in the number of minority students applying for Health Sciences seats in our collective programs. We suggest that the OP conduct a survey of the patterns of minority recruitment over the past five years to determine whether there are trends indicating an overall decline in students asked to join our programs and the number of students accepting the admissions offer. If there is such a decline, then we must determine whether there are special groups who are most affected and attempt to determine reasons why entry into our programs is declining among these groups.
  6. The organization and implementation of Health Sciences Education Programs must be reflective of overriding values and goals pertinent to the perceived health needs of the citizens of the State of California. There must be a match between what we do in education and our priorities reflective of statewide needs. As we reach very quickly the turn of the millennium, there should be a University-wide blue ribbon committee, working in conjunction with State Health Officials, to outline a Master Plan projecting:
    1. The need for manpower in the various Health Sciences Professions.
    2. The kinds of services needed relevant to the changing population demography of the state.
    3. The highest basic and clinical research priorities that will reflect the public's health and well being.
    4. The adequacy of current clinical facilities within the University and other health institutions.
    5. The relative need for primary care and specialist physicians and other health care providers in the next decade.
    6. The projected needs of Health Care Providers in under-served areas of the state.
    7. The problems of attracting and retaining Academic and Clinical Faculty in the current economic climate.
    8. The development of new strategies for financing high quality clinical teaching in our academic institutions; including review of 19900 positions, re-calibration of professional tuition fees, return of research overhead monies, and entering into new financial arrangements with private health care providers and insurance companies. The University must also continue to take the lead in presenting the case of Academic Health Centers to the Federal Government and assist in consulting on new legislation to preserve the continuity and excellence of our teaching programs.
  7. Such a master plan must be reflective of the impeding crisis in Health Sciences Education and its potential impact on the well being of our citizens. We cannot continue just to sew and patch our current programs. They will lose experienced and talented teachers and fail to recruit new ones if this challenge is not vigorously addressed. We cannot count on our past reputation for leadership excellence into the new millennium. Our students and teachers must be given the right resources to build upon our successes of the past.
  8. The HSEC is ready and eager to take its place in such a sweeping appraisal of the needs of the Health System. It can play a vital role in monitoring the success of such a Master Plan and feedback, new thoughts, and data on how best to enhance our programs. Research in Health Sciences is constantly creating new knowledge and techniques for the diagnoses and treatment of patients and the prevention of illness. We must have the best students, best teachers and best facilities to incorporate such emerging knowledge into the practice paradigms of the future. It is vital in the coming years that UC learns how to best balance fiscal prudence and realism (with regard to the Health Sciences) with a continuing commitment to academic excellence. We believe that the HSEC can play a vital role in finding that delicate balance.

Special Reports:
University of California Davis School of Veterinary Medicine
University of California San Francisco School of Nursing
University of California Los Angeles School of Nursing

University of California Davis School of Veterinary Medicine

Mission - Veterinary Medicine encompasses those aspects of biology and medicine dealing with the nature and control of disease and the health of all species of animals. Its main function is to provide for the health of all animals including livestock, poultry, companion animals, wildlife, exotic animals, birds, and aquatic mammals and fish. Veterinary Medicine also has primary responsibility for the control of zoonotic diseases, those which are transmissible from animals to humans and are capable of causing illness, debilitation and loss of human life. Veterinary Medicine contributes significantly to the advancement of biomedical science through studies on animal biology, animal diseases and animal disease models of human disease.

The School seeks to advance the health of animals through a balance of education, research and service programs. Our programmatic thrust for the 21't century is focused on animal, environmental and public health aspects. The School's professional DVM educational program is designed to educate future veterinarians for the practice of veterinary medicine. But even more, the faculty seeks to train health professionals with the skills to promote lifelong learning and the integration of knowledge for the benefit of animals and humans.

The School is the principal health resource for California's animal population. In the pursuit of knowledge and public service, the School recognizes that there are no geographic boundaries; disease does not respect national borders or sovereign countries. The School assumes responsibility for contributing its competency and knowledge about animal health and disease to State and Federal agencies as required by societal demand and responsibility to protect public and environmental health.

Facts and Figures - The School administers a large, diverse program within the University of California. This includes professional, graduate professional, graduate clinical, and graduate academic educational programs; research programs in basic, applied and clinical disciplines of veterinary medicine and comparative medicine; and a broad array of service activities targeted to the people of California

The School enjoys strong affiliations as evidenced by participation in numerous joint programs with the School of Medicine, College of Agricultural and Environmental Sciences, and the Division of Biological Sciences. The faculty participates in 17 graduate groups on the campus in biological and environmental science disciplines.

Applicants to the School are well qualified and the poll is highly competitive for the DVM program, (10 applicants: 1 acceptance) thereby maintaining the excellent quality of the students and subsequently the quality of the graduating veterinary professionals.

University of California San Francisco School of Nursing

The UCSF School of Nursing is one of two nursing schools within the UC system, with the other School located at UCLA. The UCSF School of Nursing was rated as the number one school of nursing in the US this year. The School, with its four departments, offers a Master's Entry Program in Nursing (MEPN), a Master of Science degree in Nursing, a Ph.D. in nursing, and a Ph.D. in Sociology.

The School has revised and streamlined its curriculum but ladder-rank faculty continue to teach a substantial number of courses and to work directly with the masters and doctoral programs. The School relies heavily on clinical non-ladder faculty and volunteer clinical faculty for teaching its clinical programs. Further reductions in programs are not possible because of the professional g requirements for students. The School is funded at a ratio of 1 faculty to 8 students but actual ratios are higher, although professional standards for clinical g of nurse practitioners require lower ratios. In order to cope with the funding cuts in state 19900 funds and a number of federal nurse training grants, and to maintain the standards in the teaching program, School of Nursing faculty have had to assume greater workloads and they have less time for creative research and scholarship.

Summation of the Schools needs and concerns:

  • There is a major need to be able to increase professional fees in order to afford to pay faculty for clinical training activities to meet professional training standards.
  • Distribution of overhead funds from indirect cost recovery from research needs to be improved with more going back to the School and its programs.
  • There is a need to increase clinical fee revenues. At the present time these are limited because the UCSF hospitals and clinics do not allow nursing faculty to bill directly for their services as physicians are able to bill.
  • A large number of clinical faculty are paid out of existing 19900 academic funds from unfilled FTE. These funds are not indexed to allow for cost of living and merit increases for the clinical faculty. Since clinical salaries are increasing at a higher rate than academic salaries, this creates another financial pressure on the School.
  • The current UC faculty to student ratios disproportionately favor medical school faculty, who have a ratio of I faculty to every 2-3 students. The School has a faculty ratio of 1:8 but its actual clinical requirements are for a ratio similar to the ratio for medical schools.
  • Ladder rank faculty are growing older and there are insufficient junior ladder rank faculty. -There are insufficient funds for capital equipment and basic faculty support. -The collaborative relationships with the School of Medicine are weak.

The UCSF-Stanford Merger has created particular issues for the School of Nursing:

  • A substantial amount of core support for the MEPN program is received from the hospital but none for its master's program.
  • Nursing is not represented on the advisory committee or administrative board of the UCSF-Stanford Hospitals and Clinics.
  • There is no formal structure or process for Nursing faculty and clinicians to jointly plan, coordinate or evaluate clinical education and training on the campus.
  • The Medical School controls the training and practice sites and has limited access for the School of Nursing students. There has been loss in primary care training sites resulting from nurses not being allowed to be primary care providers in the UCSF Brown and Toland Medical Group.

University of California Los Angeles School of Nursing

The School of Nursing has 33 state supported (1 9900 funds) faculty FTE and 14 faculty on soft money. It has 3 teaching programs: a small (14 students) baccalaureate program that trains nurses who graduate from community colleges; a masters program (253 students) that trains advanced practice nurses as nurse practitioners, nurse midwives, nurse administrators and clinical specialists; a Ph.D. (doctoral) program (40 students) that trains nurse researchers in biobehavioral research and health systems and services research.

Currently, the School, faculty and students are vital, positive and productive. However, this vitality and productivity depends on cooperation and collaboration of over 150 preceptors (Assistant Clinical Professors) who provide clinical supervision without salary, interdisciplinary experts from other Schools and departments who provide guest lectures, and stable financial resources from state, private, and medical center funds.

Summation of the Schools issues and concerns:

  • A majority of the master's students are becoming nurse practitioners-primary care providers. A concern is that there may be future saturation. There needs to be a UC-wide plan to assess the number of p care providers needed in California, including nursing and medicine. -There are no resources within UC to support clinical teaching. In the past the University Hospital provided the funding support and site support/resource. Today the Dean is working to get GME funds. In the era of managed care, the managed care industry provides no financial support. The School maintains contracts with over 150 clinical sites with unpaid clinical preceptors providing clinical supervision. It is getting more difficult to obtain clinical sites and preceptors due to the cumbersome University contract that must be used to obtain sites. A standard and more streamlined contract should be developed.
  • The School brings in about $6 million dollars in extramural grand funds. Only 6% of the overhead is returned to the School (contrast to Public Health 20%; Dentistry 11%). If more overhead money were to be returned, more intramural research start-up money could be granted.
  • Faculty and students convey a desire for interdisciplinary health sciences education in the classroom and in clinical practice settings. Consideration should be given to developing an undergraduate program with the participation of the Schools of Nursing, Medicine, Public Health and Dentistry.
  • The State of California needs a plan to address the predicted nursing shortage and to nurses for those areas in which there is a deficit.

The past five years have seen enormous change 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. Traditional modes of patient care, such as fee for service, have largely been replaced by HMOs and Managed Care Systems. 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 University Committee on Educational Policy (UCEP), 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 existing 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 officio members from University Committee on Planning and Budget (UCPB), UCEP, and University Committee on Research Policy (UCORP), or delegated to approve current members of these committees.

The Chair, Vice Chair, and members are appointed by the University Committee on Committees (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, M.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.

Following the establishment of the Committee, elections were held to appoint representative members and it held its first meeting on April 29, 1997 at UCSF. At this time it was addressed by Dr. Sandra Weiss, the Chair of the UC 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.


The Medical School Programs have achieved the highest standards for student education, postgraduate education (residency) clinical and basic scientific research and the provision of outstanding clinical service. This has been done in a climate of financial uncertainty, rapid reorganization of clinical sites and services, continuous technological innovation, and serious debate over issues of the proper size and responsibilities of the physician work force. Our schools continue to attract outstanding students, who do well on national exams and compete for the most prestigious residencies and fellowships. Despite these successes there are many problems which must be solved in the near future if we are to continue to be leaders in education and research. These will be addressed below.

The most serious issue confronting our Medical School Programs is in the area of clinical teaching. In all the settings which we visited, concerns about real and potential problems in this arena were paramount. There was concern that rapid and major changes in the delivery of health care resulting from market driven pressures were seriously eroding our ability to impart clinical education to students throughout the system.

There was inadequate funding available to support the extent and quality of programs needed for medical students. Program Directors and deans unanimously agreed that if any new funds entered the system they would purchase more clinical teaching time.

The increased demands upon clinical teachers to be more productive in seeing patients have decreased their time and enthusiasm for clinical teaching. We heard many complaints that not only is it difficult to teach in HMO and Managed Care settings, but that it is discouraged, and in certain settings is punished by loss of clinical income. This has resulted in a number of valued teachers leaving UC for other academic or private practice settings. Some state that -if they are going to be penalized for time spent teaching, they might as well be in a purely practice setting.

Because of the increased competition between academic and nonacademic health delivery system over the price of delivering care, there have been instances of loss of patient volume within our system. It is clearly more expensive to deliver medical services within an academic setting because of costs of training and research. Thus, patients will be driven from our academic medical centers by price considerations. This can result in loss of clinical opportunities for students. The response by our AMCs has been to extend further into the community, by buying up practices, forming unions with other hospitals, and competing for HMO contracts. This has led to a more businesslike atmosphere where the needs of the students may be sacrificed to financial considerations. It also means that many clinicians come into the system with little background in teaching or research. There is a clear need to 'buy' more teaching time within systems that traditionally have not been academic settings.

Our Committee strongly felt that we need a task force from within our own committee to address ways that the UC system can develop strategies to deal with this issue. Such a task force should work with educators within the system, administrators and Regents to explore the extent of this problem; to develop potential new sources of funding available to improve clinical teaching, form alliances with HMOs and Managed Care Companies concerned with medical education, and explore strategies being developed elsewhere throughout the country.

Another critical issue which has arisen throughout the system deals with changing patterns of admission to medical schools. The various campuses have tried to insure that their incoming classes reflect the diversity of the population of the State and that opportunities are offered to students from disadvantaged backgrounds. There is concern that our system's outstanding record in this area is changing because of a variety of political and financial pressures. We felt that it is vital that physicians be graduated from our schools who have a commitment to working in underserved areas of communities and who demonstrate the cultural competence to understand the needs and attitudes toward health of a diverse population. This is a complex problem that our committee wishes to explore in depth in the future, to develop strategies for ensuring that the full range of our citizen population can receive a quality medical education at a UC School. Greater statewide coordination of aspects of the admission process may be necessary to achieve this end.

Vital to the intellectual and scientific vitality of the UC health sciences education system is the successful recruitment and retention of Ph.D. graduate students. Our committee has learned that, though we have a very successful record in competing nationally for such students, there is increasing competition for the brightest and the best from private universities. This is the case because of more bountiful financial packages privates can offer. The graduate students represent an investment in the future growth and creativity in the biomedical sciences. They are a critical component in helping UC to compete successfully for federal and private grant monies and to form a pool of potential research faculty for the future. Graduate Deans have told us of the plight of providing adequate financial support for this group of students and feel the need that this problem be addressed by the UC Academic Senate as a priority issue.

Our committee has been impressed by the rapid growth of technology in the sphere of medical education and an increased concern with better techniques of organizing and presenting knowledge and skills to students. There has been considerable innovation throughout our system in devising new curricula, means of assessment and evaluation of student knowledge and skills and ways of presenting information compatible with the needs of adult learners. Yet these changes have grown up in comparative isolation within the system. It is important that we address Health Sciences Education as an important discipline and arena of knowledge in itself. UC has the opportunity to- lead the nation in studying the process by which students develop as physicians (and other health professionals), how new technology can be best used in facilitating learning and how acquisition of knowledge can be made a lifelong commitment. We have therefore proposed the development of a UC Systemwide Institute for Health Sciences Education. This institute without walls would bring together educators, other faculty, students, and guest teachers in a series of workshops, lectures, seminars and research projects to study and develop our methods of teaching and evaluation. This proposal is presented in greater depth as an Appendix to this report.

The question of lifelong learning in medicine and the health sciences is critical to maintaining and advancing knowledge and skill after graduation from school and postgraduate training. So-called 'continuing education' or 'extended education programs' have been an afterthought in medical education. Yet there is a greater demand for specialty recertification and demonstration of clinical competence by health care organizations. In the past, continuing education programs have consisted of a series of lectures or workshops over a limited number of days. There are exciting new possibilities for improving such learning through the use of new technologies such as CD ROMS, telecommunication and individualized training modules. Our committee believes that over the next year, we can develop a working group to make recommendations helping to improve how we help our graduates and other practitioners in the state continue to refine and improve their clinical and research skills.

The committee believes that we have just begun our work of assessment and recommendation to improve education in health sciences. There are still six more programs to be visited and work on the above recommendations is still to be achieved.

The committee unanimously felt that it had an important contribution to make to the educational understanding and the policy of the UC system and recommends that its mandate be continued in the future. It is probable that we will not need to meet on a monthly basis as happened in this inaugural year, and that much of our future work can be accomplished using smaller study groups and electronic communication.

Members of the committee have been enthusiastic with the work in which they have been engaged in the past year and about continuing to build on findings of the previous year and carrying through with the recommendations which were discussed in this report.

Summary Report Of Committee On
Health Sciences Education


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.


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.


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.



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.


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.



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.


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.


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.


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?


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.


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.


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.


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.


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.


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.

This is the second installment of the Health Sciences Education Committee Report on our activities covering the academic year 1998-1999. In our earlier report based on our survey of all the UC Medical School Programs, we noted that there were serious problems in health sciences education, triggered by financial pressures at the Academic Medical Centers. All Centers were effected by significant reductions in Federal Medicare Payments for education and the negative impact of Managed Care Plans on the level of financial reimbursement. The major result of these constraints was diminished support for clinical teaching. We noted that faculty felt pressured into seeing ever-increasing numbers of patients, resulting in reduced time for instruction, supervision and mentoring of students. This has produced a decline in faculty morale and has impelled an ever-increasing number of them to consider leaving academic work. They experience a reduction of the gratifications of academic life, which includes sufficient time to perform quality teaching, conduct research and engage in meaningful collegial interactions. The quality of academic morale was perceived as eroding in this changed fiscal environment. The diminished morale of the faculty will inevitably lead to problems in student education.

Financial difficulties were also evident (in some settings) in the neglect of certain physical facilities, such as classrooms and laboratories. Adequate support for graduate Ph.D. students, working in the arena of biological and behavioral health research was also frequently viewed as a problem on some campuses.

Despite these difficulties, the level of instruction and student satisfaction remained high. However, our committee had concern that this was an unstable situation systemwide, which was progressively getting worse. The decline of clinical revenues relative to cost seemed incremental and, in some institutions, draconian cost-cutting measures were taking place. This has been dramatically illustrated by the substantive UCSF/Stanford Health Center deficit. There is concern throughout the system that clinical care as well as student education would eventually suffer. Thus, the public mandate to educate outstanding, well-trained health professionals and deliver the highest quality of clinical care to the citizens of California was in jeopardy. Members of the medical faculties are responsive to the critical nature of this situation and have put forward increased productivity and renewed commitment to deal with this stressful situation. Yet, the committee felt last year and continues to feel again, that the strain on our academic health programs has already reached a critical level and calls for creative new initiatives to secure our future academic survival and further our tradition of excellence. Anecdotal reports that have reached the Chair of the HSEC tell of students bursting into tears when they talk of their community experiences with young clinical faculty who tell them with sorrow and regret about their current situation as physicians. Several students who looked forward with idealistic anticipation to a career in medicine are now questioning their choice of profession.


This year the committee was enlarged by the addition of several members. These included representatives from Santa Cruz and Santa Barbara campuses, the Vice Chair of the Academic Council and the Chair of the Coordinating Committee on Graduate Affairs. The inclusion of representatives of various Senate Committees, in addition to those from health sciences programs, was a very positive aspect of our work. It permitted interdigitation of information from other aspects of University life with HSEC and also provided those committees with input about issues in the health sciences. There was a general consensus among committee members, however, that in the future, the size of the HSEC could be reduced because of convenience and resource preservation.



DAVIS - SCHOOL OF VETERINARY MEDICINE: Yuan Chung Zee, Pathology, Microbiology & Immunology

IRVINE - COLLEGE OF MEDICINE: James Fallon, Anatomy & Neurobiology

LOS ANGELES - SCHOOL OF MEDICINE: Thomas Drake, Pathology & Laboratory Medicine
LOS ANGELES - SCHOOL OF PUBLIC HEALTH: Jane Valentine, Public Health/Environmental Health Science

RIVERSIDE: Ameae Walker, Cell Biology

SAN DIEGO - SCHOOL OF MEDICINE: Peter Wagner, Department of Medicine

SAN FRANCISCO-SCHOOL OF PHARMACY: Betty Ann Hoener, Biopharmaceutical Sciences

SANTA BARBARA: David Martin Kohl, Developmental Biology

SANTA CRUZ: Nancy Chen, Medical Anthropology

Academic Council Vice Chair: Lawrence B. Coleman, Physics, Davis
CCGA: Richard Shafer, Pharmaceutical Chemistry, San Francisco
UCEP: Catherine (Kit) Chesla, Family Health Nursing, San Francisco
UCORP: Carroll Cross, Pulmonary and Critical Care Medicine, Davis
UCPB: James Given, History, Irvine

Committee Analyst: Louisa Tapley-Van Pelt Universitywide Academic Senate staff


During the current academic year our committee visited and reviewed the following programs:

  • School of Dentistry: UCLA
  • School of Nursing: UCLA
  • School of Public Health: UCLA
  • School of Dentistry: UCSF
  • School of Nursing: UCSF
  • School of Pharmacy: UCSF

In 1997/98 the following schools were visited, but not reported on in our previous report:

  • School of Optometry: UC Berkeley
  • School of Public Health: UC Berkeley
  • School of Veterinary Medicine UC Davis

In addition to our program's evaluation activities, the committee has appointed three task forces (subcommittees): 1) to make recommendations concerning improving clinical teaching, 2) to explore ways of improving evaluation of programs and students in the health sciences and 3) to develop an Institute for Health Sciences Education within the UC System. These will be further described at the end of the report.

Major Findings on Program Review:

  1. In all the programs that we reviewed this year (particularly in Nursing and Dentistry), there is a perceived increased heavy strain on clinical faculty. In several of the programs, FTE positions have been lost while the teaching load has increased. In all of these schools, there has been an attempt to expand the scope of the educational responsibilities by creating new degree programs and increasing outreach into the postgraduate professional community. The financial and emotional resources of many departments have been severely stretched. Several faculty members told us that either they or their colleagues were considering leaving academia because of the increased burdens and declining administrative support. This has been especially true in the non-paid clinical faculty and in the non-tenured full-time faculty lines.
    The committee was impressed with the dedication, hard work and loyalty of these faculties who felt that they and their programs had reached (under the present circumstances) the limits of innovation and effort. The general perception is that the programs are currently marking time or in gradual decline, given the constraints on resources and the increased burden of work. Many faculty, particularly those in Schools of Nursing, felt that they were working far beyond the hours for which they had been paid. They believe the high national rankings of these programs, which are a source of pride to the University, are in large part due to the efforts of talented, loyal and over-worked staff.
  2. The issue of space was a major concern among all these programs. This was particularly evident with regard to research space availability. All of these programs pride themselves on their research record, both in terms of the quality of investigations and the success in obtaining federal funding. However, there is a disparity between the research capability and space (and administrative resources) available. UC programs in all of these domains rank among the very highest in the country, in part because of the quality of research that is produced by the faculty. This reputation is important for advancing clinical and basic understanding of health and disease issues, as well as assisting in attracting outstanding graduate students.
  3. There continues to be difficulty in attracting classes of students that are representative of the ethnic and racial diversity of the state. In the Schools of Dentistry, Nursing and Public Health this continues to be a problem. There were a variety of reasons given for the relative absence of these groups of students. Some felt that the high reputation of the schools might intimidate some students, others believed that more students of color were selecting careers in business rather dm the health professions. Because of the needs for outstanding health care in -underserved communities in our state, the inability to recruit these students is a serious problem. More time and resources must be made available to reach out to diverse ethnic students early in their education, to rectify this problem.
  4. The explosion of knowledge in the health sciences and the need for continuous curriculum review and reform has stretched the resources of most health education programs. There is a need to utilize current technology to present and inform students of the most contemporary knowledge in an effective and efficient manner. The use of simulated patients on CD ROM discs, the utilization of telecommunication for distance learning, are part of the evolution of new teaching techniques. Yet, the best methods of current instruction are often very expensive to produce. Over and over again in all the programs there was a wish for more collaborative, multidisciplinary efforts among the various programs. The demands of a modem curriculum are such that very few of the Schools outside of Medicine have the expertise to mount entirely on their own courses and instruction of the highest caliber, without sharing of teaching resources.
  5. A common theme voiced by all the programs we visited was the need for more multidisciplinary cooperation and teaching. The various schools of Dentistry, Nursing, and Public Health regarded themselves as virtually invisible on their collective campuses. They believed that there is very little academic recognition of either their contributions to clinical health care, community service or research. Frequently, attempts at furthering collaborative teaching exercises or sharing of resources are ignored. There is a long history of FTE positions in both Dentistry and Nursing being given to their associated medical schools to buy teaching time (particularly in the basic sciences). Often this arrangement works out mutually very well, but there is a feeling that there is little control over who will be doing the teaching and how this can be calibrated to their particular professional needs. Generally, there is a desire to have more say over what this resource allocation will buy.
    There is, likewise, a belief held by all the health sciences Schools on general liberal arts campuses, that the CAP committees do not recognize the unique teaching responsibilities and burdens which fall upon their faculty. Such committees often do not appreciate that traditional Arts and Sciences criteria for advancement may not be applicable to professional school faculty. Thus, there is a wish to rethink the traditional structures of the Universities with regard to governance and resource sharing as it affects the future of the health sciences. This has raised the question for the HSEC, during the course of our deliberations, as to whether new ways of organizing the health sciences to meet their clinical, academic and community obligations may be necessary.
    Clearly, in the arena of curriculum design, evaluation of clinical performance, development and use of technology for instruction, greater collaboration and sharing of resources and ideas is necessary. There is much duplication of educational effort that occurs in the health sciences today. It is inefficient for each program to design duplicate materials and tools of teaching across the system.
    It was with this perspective in mind that the HSEC has suggested the development of an Institute of Health Sciences Education, which would span the Entire University of California system and ensure greater planning, development and sharing of resources. The current system of the health sciences organization, despite its many spectacular successes, is somewhat inefficient and unprepared to deal with important changes in the various professional schools. New, more functional means of bringing faculty and students together around issues of common concern must be found to supplement the somewhat feudal arrangement, which exists today. Traditional roles of clinical care, research and teaching are changing rapidly through the health domain. Organizational arrangements must also alter to take these new roles and tasks into account.
  6. There is a crisis in maintaining and expanding community clinical training sites, both for Dentistry, and Nursing students. Our schools of Dentistry, Nursing and Pharmacy have reputations for being at the very top of national renown for attracting and graduating students who enter clinical practice. These schools accept a large number of students into their clinical degree programs, more than can be accommodated for clinical experience on their respective campuses. They are dependent on finding and maintaining clinical clerkship sites to train their students. This entails entering into complex arrangements with various off-campus clinical sites (pharmacies, dental clinics, outpatient clinics) to train their students. To accomplish this task, the professional schools must utilize the services of a very large number of volunteer clinical faculty to oversee the training of these students. In recent years, there has been increasing pressure placed on our programs to maintain the existence and training integrity of these sites. This is true for the following reasons:
    1. The pressures of managed care have made it more difficult for faculty to have the time and energy to spend with students.
    2. In certain managed care clinics, patients are often seen for ten minutes or less, making for a very rushed clinical experience for the patient, student and instructor. This is particularly true in Nursing.
    3. UC has traditionally not paid its off-campus sites for the right to utilize their facilities for training purposes. Yet we are under increasing pressure from private professional schools for access to these sites. It has become customary for other schools (e.g., University of Pacific School of Dentistry) to pay the off-campus clinics a certain fee per student for the right to use that location for training. Thus, it has become difficult to either expand our presence in these sites, or in some instances, to maintain our current student numbers under the circumstances of this competition. Erosion of these arrangements threatens the integrity of the clinical teaching programs in the various schools. Under present circumstance, however, there is no additional funding for offering stipends for training locations.
      Most of our Professional Schools do not have the individual resources to deal with the threats to clinical teaching access. Shifting full-time research faculty to take over for volunteer faculty is not practicable. This would erode the outstanding research reputation and contributions of these schools and make hiring of new faculty more difficult. Some switching of responsibility has already taken place, but there are severe limitations on the time and geographical availability of full time department members. It takes an enormous effort to find, secure, maintain and supervise off-campus sites. By and large, the students are currently happy with the ongoing arrangements but recognize the tenuousness of the current situation. Attention must be paid to retaining and rewarding volunteer faculty who are the mainstays of our clinical programs. How this is to be done is a major problem for maintaining both sites and the quality of teaching.
      An additional problem is the confusing and complex contractual requirements which must be traversed in order to obtain access to clinical teaching sites. It has been suggested that the University develop a universal contract template to simplify this process.
  7. A common concern raised by all of the professional school deans and faculty has been the freezing of student professional tuition. They understand the social and political unpopularity of raising student tuition in this state and yet assert that, without more income from this source, the quality of education will diminish. There are needs for refurbishing equipment and teaching sites, need for more administrative help and certainly urgent requirements for additional paid clinical faculty.
    Because of problems of staffing clinics in Dentistry, some students are unable to see the State mandated number of patients necessary for graduation. A fair number of these students must delay graduation in order to fill their required number. It has come to our attention that some students must pay patients to come to clinic to satisfy their degree requirements. This is a very unfortunate position in which to place our students, and this practice delays their entrance into the work force. Thus, careful attention must be given on a Universitywide level to the consequences of this policy of tuition freeze. The ultimate decision lies with the legislature, but it is our responsibility to inform them of the consequences of this policy over time.
  8. A related issue is the question of the Student/Faculty Ratios in the non-MD Professional programs. The Schools of Nursing, for example, have an 11/1 ratio but have enormous responsibilities for training Masters level and Ph.D. students. This is a very labor-intensive task and yet, over time, both Schools have lost rather than gained faculty.
    It appeared to our Committee that the Schools of Nursing, Pharmacy, Dentistry and Public Health have reached a critical resource limit. It is questionable at the present level of financial support and the increased costs of education that they can sustain and increase their current teaching load. It is important for the State to assess what its future needs will be in these areas as the population of California grows. An increase in immigrants, the elderly and the young will call for more rather than less resources in these areas. Will the University be able to train clinicians and leaders in these professions in the future, given current financial constraints? The alternative will be the rise of more private professional schools at higher cost to the students. We have been told that UC professional school students have a considerably lower debt load than those in private institutions. The economics and efficiencies of a moderate professional fee rise should be considered in light of the alternatives.
  9. In the Nursing Schools, the attempts to earn more money through Faculty Practice has not yielded the revenue needed to sustain clinical teaching and diminishes time available for student instruction.
  10. All of our professional schools pride themselves on having outstanding research faculties. They are highly competitive in capturing federal grants and are recognized nationally as the leading research schools in their field. Yet a constant refrain has been that the research infrastructure is not being adequately funded. Laboratory space is limited, equipment including computers is outmoded and the ability to attract creative new faculty is impaired by this situation. To quote one Dental School Faculty member, "There are serious problems with respect to capital equipment needs and insufficient resources--including space and instructional equipment. Fundamental equipment for students--the 'bricks and mortar'--is not paid for by the state. If funds were provided for that, School of Dentistry monies would be freed up for hiring junior faculty and other School priorities."
  11. The most striking finding that our Committee uncovered in all of our visits, was the profound sense of frustration by many of the faculty concerning the current lack of resources. One prominent faculty member of a School of Dentistry said that, as a group, his colleagues had exceeded accountability expectation--delivering the best dentistry school in the world. It had outstanding breadth in its research portfolio and a distinguished faculty. Yet the faculty has not received adequate resources. There are insufficient numbers of junior ladder rank faculty in tenure track positions and also inadequate numbers of junior faculty in clinical series in several departments. Full-time ladder rank numbers have also been reduced and some FTE positions have been left unfilled. Generally non-Medical School faculty see themselves as outside the realm of advice givers on where and how University funds should be spent and what are faculty and student priorities.
    From a UC School of Nursing, we hear that there are few University resources to support clinical teaching. "In the era of managed care, that industry provides no financial support for clinical teaching or research. They do not provide the clinical support /resources that the hospital did in the past. To support outstanding clinical teaching, financial resources, site availability and clinical preceptors are needed. Finally, a stable, paid, clinical track for faculty is needed for effective clinical teaching."
    Despite this sense of faculty frustration encountered, we also experienced a sense of extraordinary commitment and loyalty to their schools and its students. The excellence of these educational programs is being supported by the creativity and, indeed, sacrifice of many dedicated faculty members. Yet the sense of strain and fatigue was evident. The faculty would like to develop new programs to enhance their profession's contributions to the community but believe that the limits of their own efforts have been reached. They want resources to advance their schools and recognition by the University for their excellence and contributions to the public well-being. They do not believe that, even among their own university colleagues, that has been achieved. We were impressed with their sense of optimism in face of all the problems which they clearly detailed.


Throughout our visits to the various campuses, it has become evident that the growing complexity of the educational responsibilities within the health sciences programs requires innovative new approaches to curriculum development, communication of knowledge and sharing of resources. The traditional academic admonition of 'Each tub on its own bottom' is not adaptive in the present fiscal and knowledge environment among the health sciences. The past structure of almost 'feudal' autonomy of each academic program no longer reflects the contemporary needs within the health professions.

Traditional care-giving roles are changing in health practices. Nurses with graduate degrees are playing an enhanced role in providing primary care to patients. They are also taking greater administrative responsibilities within provider organizations. Dentists, nurses and public health professionals are becoming more active in the education of medical students and resident physicians. All of these disciplines are increasingly involved in continuing education for practitioners in the community. All these professional groups also are critical in developing important prevention programs for the public.

In the sphere of research, it was evident to our Committee that, within the UC System, the Schools of Nursing, Dentistry and Public Health have developed world-class research programs. They are national leaders in successfully competing for grants and in producing Ph.D. students who will become the academic and research vanguard of the future. All of these programs have voiced the wish for greater collaboration and integration among the School of Health Sciences.

The Committee believes (as argued in last year's report) that such collaboration can best be achieved by thinking of the health sciences as an integrated education network within the UC system. It is time to break down many of the barriers separating these programs and find ways of more effectively and efficiently pooling their imagination and resources.

A Health Sciences Institute would respect the particularly unique role that each program plays on its home campus and demographic locality, but it would also provide a flexible and focused home for meaningful inter-school and cross-campus collaboration. Obviously, this concept would evolve over time with considerable input from faculty, students, deans and administrators. Yet, as currently envisioned, it could develop organizational structures to foster sharing of ideas and creating new protocols in the following domains:

CURRICULUM DESIGN - With the rapid advance of knowledge in the biomedical and behavioral sciences, there is a need to constantly update curricula for students and develop methods to teach these skills. Throughout our system, a wide variety of methods are being developed and implemented to learn how best to impart clinical abilities. Again, there is minimal sharing of innovations and little cross-campus or school conversation about finding new, effective means to do this. A systemwide INSTITUTE could be an effective vehicle for sharing past experiences and mutually developing new methods.

TOOLS FOR EVALUATING STUDENTS, FACULTY AND COURSES - A critical component of Health Sciences Education lies in evaluative processes. How best to assess student learning of skills and basic professional attitudes and values is currently more art than science. Yet contemporary demands in the health marketplace will put a greater emphasis on assessing what graduates have learned and believe, when they seek positions. So, too, evaluating faculty performance becomes a complementary requirement in the current educational environment. The kinds of 'high precision' tools for carrying out such evaluations should be developed and shared throughout the system; this is a task that the INSTITUTE could initiate and implement.

ASSESSMENT AND DEVELOPMENT OF CUTTING EDGE LEARNING TECHNOLOGY - There is an exposition in the way in which information is coded, stored and displayed. Any world-class educational system needs to be constantly aware of how technological advances can enhance student learning. The UC system has -enormous resources for being a leader in developing and testing new technologies for Health Sciences Education.

The Institute can play a major role in exploring national and worldwide trends in educational technology and perhaps enlist the cooperation of major California firms in developing cutting edge new tools for use in the health sciences field.

There is a growing awareness that ADULT LEARNING requires sophisticated cognitive approaches to knowledge and skill acquisition. The Institute can take advantage of the many renowned cognitive psychologists and educational experts in our System to study how mature students best acquire and retain information and use it appropriately in health care settings. Learning to be a practitioner requires complex processes of storing, accessing and using knowledge, often under conditions of uncertainty. We know little at present about how novices can become mature clinicians and clinical scientists. The Institute can study these mental and skill processes and use their findings to develop more focused and effective teaching tools. There is also a need to understand how practitioners learn to incorporate new research information into their clinical practice and maintain and advance their skills. We know very little about how older health professionals maintain a stance of lifelong learning and acquire new methods, values and attitudes in their practices. There is a need to recognize that cognitive approaches useful at one point in ones career may not be efficacious later in life. Can patterns learned early in training be altered with the accession of new knowledge and practice patterns?

PUBLIC POLICY AND HEALTH SCIENCES EDUCATION: There is an important linkage between evolving changes in public policy on a local, state and federal level and the opportunities and problems of health education programs. Changing funding policies, licensing issues, accreditation standards, reimbursement protocols, all effect the structure and functioning of professional health sciences schools. There is a need to collate, analyze and communicate about critical issues in Health Policy throughout our University system. There is also a value in being able to interact with important health policy officials through lectures, symposia and personal interaction. The Institute can act as a clearinghouse for developing issues that affect our Schools, provided through a web-site reaching all campuses and schools. Timely understanding of changing policies and the ability to form a systemwide response can only help to better prepare our programs for the future. A parallel effort should also be made to communicate with Health Maintenance Organizations, which play a role in our clinical programs.

FOSTERING RESEARCH COLLABORATION: Much of the discussion concerning the Institute has focused on Clinical Training. Yet, equally important is the role of Research Education within the UC System. There are a myriad of ways in which fostering better communication between the various schools about ongoing research activities, availability of funding for students, and new directions in technology can be of immense value in assisting our many students who engage in research. There is also an evident need to help our clinically oriented students understand how emerging research findings can benefit their practice.

The Committee has outlined a series of tasks, which an Institute for Health Sciences -Education can perform. We believe that there is a desire throughout our system to facilitate more interdisciplinary collaboration and dialogue among educators. Many schools today feel isolated and invisible from the larger University. New, more fluid structures are necessary to mobilize the considerable expertise and wisdom within the University to meet the challenges of the future.

Special Reports On The Schools Of Pharmacy,
Public Health And Optometry

Most of the problems reported above with regard to funding, clinical teaching, clinical placement sites, faculty morale and diminishing resources apply to the Schools cited above. However, each of them has a unique mission and issues which suggests that their current situations should be reported upon separately. Each of these Schools is distinguished nationally in its respective field. Each serves the health needs of California well by its service to citizens, training of students and creative research contributions.

I. SCHOOLS OF PUBLIC HEALTH - There are two Schools of Public Health within the UC System; one at Berkeley and the other at UCLA. Each represents a vital component in our health care system, addressing issues of policy and research that effect the well being of the California population. Many of the important advances during this century in reducing morbidity and mortality of disease arises from the work of Public Health graduates. They, like their clinical counterparts, have complex roles in g and research. They are also beset with many fiscal problems.

A. The School of Public Health at Berkeley

Background - The School of Public Health (SPH) is one of the 13 professional schools on the Berkeley campus, and consistently is ranked among the top public health schools in the nation. This ranking is impressive since the other leading schools (e.g., Harvard, Hopkins, the University of Michigan and the University of North Carolina) typically have 10 times the faculty size of Berkeley, with its 40 FTE. Student enrollment in the SPH is about 425, and in addition to its ladder rank faculty, the School has approximately 20 adjunct professors, 18 clinical professors and 30 lecturers.

Strengths of the School include the national and international reputation of its faculty, who bring in $15 million in federal and foundation research and training grants each year, and many of whom are members of prestigious groups like the National Academy of Science and the National Institute of Medicine. The high quality of its students is another major strength and, to its credit, the SPH has been able to maintain cultural diversity among its student body in the aftermath of the ban on affirmative action. The School also has active and prominent alumni in many diverse areas within public health, many of who remain strong supporters of the School.

Other strengths of the School include its community outreach, through the Center for Community Practice, which arranges field placements for most of the School's students, and the Center for Family and Community Health, a federally funded center for health promotion and disease prevention research on the community level.

The School also boasts the internationally known University of California, Berkeley Wellness Newsletter, which has over 500,000 subscribers and brings both visibility and royalty revenue to the School. Annual private donations to the SPH have increased almost tenfold since the early 1990s and a high level external advisory group (the Dean's Policy Advisory Council) of national leaders in industry, philanthropy and public affairs also has assisted with both visibility and fundraising.

Limitations and problem areas - Despite these strengths, the School faces a number of serious limitation and weaknesses. One of the most serious of these--the total inadequacy of facilities and space - is to be remedied with the tearing down of Earl Warren Hall, due to seismic problems (slated for the next 2 to 3 years), and its replacement with a new building that will house public health, as well as neurosciences and related disciplines. In the meantime, however, faculty and staff are dispersed across six campus buildings, plus off campus rental space, which decreases opportunities for interaction.

A second major limitation is in the area of research administration. -The School currently ranks in the top five campus units in external research support per faculty FTE. Yet, unlike units which receive supplemental funds for research administration -through ORUS, the School must fund the cost of research administration from its instructional budget. From 1992 to 1997, the School experienced a 60% increase in extramural research and g support, with little or no return of indirect costs to support these activities ($15,000 annually to support $15 million in annual extramural research and g grants), and this trend has continued. This situation needs to be remedied and a more equitable arrangement devised.

A third major weakness lies in the loss of faculty and programs in the area of behavioral sciences and health-education. Although the School recently admitted (for fall 1999) its first class to a new Area of Concentration in Health and Social Behavior, this program is essentially unfunded and has no Divisional home. The recent loss of an internationally known faculty member in behavioral sciences, and the failure to fill slots vacated by retirements, death, and faculty transfers to other programs over a period of many years, has left the School considerably weakened in this area. Because a strong behavioral sciences presence is necessary for accreditation, the need to recruit new FTE and to provide infrastructure for this program is critical.

A fourth major problem involves the lack of adequate student support. Every year, the School loses outstanding admits to Harvard, the University of Michigan and other Schools of Public Health which are able to offer more generous financial packages. Although many faculty provide research positions for students through their grants, and although some fellowship and TA positions are available, the unmet need remains substantial; many excellent students must work off campus in jobs unrelated to their graduate training in order to make ends meet.

The School also suffers from a lack of minority faculty. Currently, just three faculty are from underserved communities, and the School recently lost its only Hispanic male faculty member to another university whose financial package we were unable to counter. The School needs to make every effort to recruit and retain minority faculty, and, in particular, needs support from the university in being able to offer competitive salaries and support in this regard.

The faculty to student ratio at the SPH represents another major problem area. Most of the leading schools of public health have a faculty: student ratio of about 4:1, while the Berkeley SPH ratio has been as high as 11:5 in recent years. Ways need to be found to improve the state funded ratio of 8:6 (blended across all programs in the School) and to bring our ratio more in line with other top schools.

A related problem faced by the School has involved its difficulty in gaining new adjunct appointments. The Berkeley campus' stringency with such appointments poses a special difficulty for professional schools where the quality of the research and educational experience provided for students often depends on high quality colleagues who can bridge the gap between academia and practice. Particularly given our small faculty size, an increased ability to hire top quality adjunct professors (who typically teach without salary) and clinical appointments is essential.

In spite of the above substantial problems, the School of Public Health at Berkeley remains widely recognized as a leading institution in the field. If the limitations and weaknesses noted above can be remedied, it could well become the premier School of Public Health in the country.

B. The School of Public Health at UCLA

The School of Public Health at UCLA is another strong component of the UC Health Education System. Within the School, there are five Departments: 1) Bio-Statistics, 2) Community Health Services, 3) Environmental Health Science, 4) Epidemiology, and 5) Health Services.

A critical issue raised by a number of the faculty was that the SPH still suffers from the Professional School Restructuring Initiative (PSRI) instituted in the early 1990s by the previous Chancellor. This action reorganized and reduced the size of the faculty for Public Health by 25%. The number of the faculty dropped from 60 to 48 and the number of staff from 48 to 23. The School was provided with transition monies of $1.5 million but the period of transition is now over and the School is confronted with the cuts on a permanent basis. The School now faces severe budgetary problems with a deficit of $500,000>. Plans to reduce the enrollment for new admissions for 1999-2000 is 203, down from 214 during the previous three years. With the loss of funds, outreach programs to attract a diverse student body have also been cut. In addition, elective course offerings will be reduced and special teaching assistance will be lost. Students have been impacted also by the loss of a career placement staff person.

When faculty were asked about their hopes for the future development of the School, the Committee Chair was told that they need a building of their own, more full-time faculty, an increase in interdisciplinary activities, and an enhanced UCLA/Berkeley relationship.

Generally, the students were enthusiastic about their education and felt that they received good attention from their teachers. All those interviewed felt that Schools of Public Health must do a better job in making citizens, legislators and the University Administration better aware of their activities and accomplishments.


Background- Optometry is a primary care profession defined in state licensing laws. Optometrists account for about 67% of eye exams in the U.S. Laws specify curricular requirements. Graduates mostly enter private practice; some to managed care practice, some to commercial practice (especially in early years to pay off loans) or go on to residence training. Optometric practice rests upon advances reported in the major refereed ophthalmological and optometric journals.

The optometric graduate has more experience in contact lens care, redaction, diagnosis and non-surgical treatment of binocular vision problems, vision function (color, contrast, visual field perimetric measures) assessment, low vision rehabilitation, vision screening, and visual training than can be found in ophthalmological residence training. Both have training in diagnosis of posterior segment eye disease and diagnosis and treatment of anterior segment disease. In contrast the ophthalmologist has training in posterior segment disease treatment and diagnosis including surgical treatment of eye disease, where the optometrist has no surgical training.

Laws defining optometry have included pharmaceutical treatment of eye disease for over fifteen years but for only two years in California. The UC School of Optometry has offered g in diagnosis and treatment for the past decade in order that its graduates could practice in states where such was allowed by extant law. Some of the training was conducted in federally administered California facilities (e.g., VA hospitals) and in out-of-state clinics. The didactic curriculum has thus included such training for some time.

The breadth of material, and thus faculty expertise needed in the optometric curriculum includes both diverse basic sciences and clinical sciences, and differs little from that in medical, pharmacy and dental curricula.

School of Optometry at UC Berkeley--The Optometry program began in Berkeley in 1923 as a division of the physics department and is ranked as the finest in the US and Canada. It accepts about 60 new students annually into its four-year post baccalaureate program, from an applicant pool of about 350. Entering students show OCAT (similar to MCAT) scores higher than those at any other school; graduates pass National Board exams at rates higher than any other school.

The School has a student faculty ratio of 16:1 after VERIP retirements, typical of the Berkeley campus; the office of the President authorizes the Berkeley student/faculty ratio in the health sciences to be 12.5:1. However, even though the health sciences allocation is a separate line in the campus budget, the campus has not authorized that ratio. Furthermore, the campus has failed to successfully advocate a ratio more realistic than 12.5:1. The ratio for UC dentistry schools, schools whose curricula are quite similar to optometry's, is closer to 4:1, one that Schools of Optometry elsewhere advocate as far more appropriate. Instruction includes didactic coursework in both basic clinical sciences plus direct patient care responsibilities and experience in the clinical setting.

Much clinical instruction is carried out at 40 satellite clinics (e.g., Sacramento VA, Travis AFB), about half outside of California, with non-paid mentors. Suitability is ascertained on-site by a UC faculty member charged to oversee off-site rotations. Clinical faculty are paid far less than in either private practice or comparable health professional academic positions; there is, as yet, no compensation plan.

Ladder faculty in the School have an enviable record of research accomplishment and NIH support. Nearly half have joint appointments in other UCB departments or programs.

The School has cooperative and/or collaborative agreements for either research or teaching with Kaiser Hospital Oakland, UCSF Department of Ophthalmology, and Pacific Medical Center. -However, evidence of historical inter-professional acrimony can still be found. This acrimony, in the form of opposition from community ophthalmologists, recently scuttled a promising and -mutually valuable cooperative program with UC Davis. Its faculty collaborate in both research and teaching with faculty in other Berkeley departments such as Psychology, EECS, Chemistry, English, MCB, Bioengineering (new department anticipated in late 1998) and the Department of Ophthalmology at UC Davis.

The School administers a highly-ranked interdepartmental graduate group in Vision Science which graduates about 7 Ph.D's annually and which includes faculty from a half dozen other campus departments. The School also administers a residency training program in specialty areas of optometry, but receives no support for this program from either the campus or from UCOP.

Expressed needs with which the HSEC might offer assistance:

Strengthened research on clinical side: The HSEC could assist the School by helping the campus to understand the nature and role of clinical research and the need for faculty to conduct it.

Lack of funding for residencies: Eleven are approved but no UC funds are supplied. HSEC might offer assistance by advocating an equitable assignment of funding to this program for direct resident stipends.

Breadth of curriculum: The increasingly medical caste of the profession, and the hands-on nature of clinical instruction, particularly in the latter two years, argues for a student-faculty ratio (presently more than 16) more consistent with practice as in other UC health sciences schools. Dentistry would be an appropriate UC model in this regard. The HSEC could assist as an advocate of a lowered ratio and by urging the Berkeley campus to honor the excessively high but approved ratio of 12.5:1. This funding already exists as a separate line item in the campus budget.

Patients for use in instruction: This shortage could be partially relieved by identifying the School as a provider in managed care plans patronized by UC.


A. School of Pharmacy - UC San Francisco

The school is doing extremely well in terms of research funding (#1 in NIH funds--nearly 3 times the next school) and reputation (#1 in surveys). It continues to attract very bright (3.5 entering GPA, 90% with BA/BS, 80% from other UC campuses) students into its PharmD program.

A new curriculum has been developed over the last 5 years to better prepare pharmacists who will be the leaders of the profession as the profession develops and grows in the changing healthcare environment. Students will select an emphasis in one of 3 pathways-Pharmaceutical Care, Pharmaceutical Sciences and Pharmaceutical Health Policy and Management. Students now begin to practice their future profession in the first year of the curriculum. This new curriculum is even more oriented to active, problem/case-based learning. Students are working more and more in teams to both identify and solve problems relevant to their developing professional competencies.

These accomplishments have been made during a time of increasing instability in the available resources. The student/faculty ratio is I 1: I versus a 3 -4:1 ratio in the medical schools. Thus, the school must rely on a cadre of 500 volunteer faculty. These faculty have been willing to take on this responsibility out of loyalty to the school, because of their love of teaching, and to keep their own practice fresh and challenging. However, as medical centers close and/or merge, clerkship sites are being lost. Sites are also being lost to the other Pharmacy Schools (all private) in the state, which are offering dollars to support positions at the sites. The UCSF program has lost about 10% of its sites in the past 2 years. While this loss has not been felt by current students, it may limit the choices available to future students. The faculty response has been to work harder to identify nontraditional sites in emerging areas of practice.

A more significant potential loss to the school is a direct consequence of the financial instability of the UCSF/Stanford Medical Center. The school has always received financial support from the medical center in return for pharmaceutical services. At one time this amounted to $1.5 million/yr. but is now about $735,000/yr. However, the leadership in the school is very concerned that this may be in jeopardy. If it is lost, it will have a severe impact on the school. Even today, faculty, particularly in the Department of Clinical Pharmacy, have been reallocated into service roles to the detriment -of their scholarly activities. Another adverse event was the freeze placed on professional fees. The school was only 3 years into an approved 5-year ramping up to a $5000/yr professional fee. Unless this is reinstated, the school will be in deficit funding by the year 2001 (even if the medical center recovers). Also of concern is the move of about 70% of the Department of Pharmaceutical Chemistry faculty (about 40% of the tenure track faculty in the school) to the new Mission Bay campus. While this move will provide them with more and improved space to do their research, it will take significant efforts to make sure that the cohesiveness of the school is not lost.

Despite these challenges to the school, students continue to report on the accessibility and responsiveness of the faculty. They feel that they are being appropriately challenged to become leaders and to develop their own careers.

B. Additional comments related to Schools of Pharmacy within California

The role of the pharmacist has changed over the years from dispensing and compounding of medicinals to that of a therapeutic consultant. With the human genome project scheduled to come to fruition and the expectation that genomic databases will soon be used for optimizing therapeutic outcomes and predicting drug interactions, the role for properly educated pharmacists as therapeutic consultants will increase.

Given the expanded professional expectations and given that the entry-level degree is now a Pharmacy Doctorate in California, pharmacy lacks a sufficiently broad base of practicing .pharmacists that can serve as preceptors for clerkships and internships. Thus deficiency also extends to suitable clerkship -sites. The problem may be compounded -in the future with the proprietary pharmacy schools seeking locations for their educational and clerkship endeavors. Many of these schools have become very entrepreneurial in their expansion plans for students, yet lack the traditional in-house facilities for proper training.

Traditionally, the hospital pharmacy has been an important revenue generator for teaching hospitals, and this source of funding has supported clinical teachers. With the impact of managed rare and the Balanced Budget Act of 1997 on financing the education and service missions of teaching hospitals, this source of support has virtually disappeared. Clinical teaching must be done in small groups in patient-linked settings, necessitating higher faculty to student ratios.

As alluded to above, formulaic bases for faculty to student ratios in pharmacy were set long before changes in the educational structure where the entire fourth year is clerkship based and some introductory clinical teaching occurs in years 1-3. Hence, current formulas do not reflect faculty activities in clinical pharmacy.

A premier school requires the facilities for faculty to be competitive for federal and industrial research support. To achieve appropriate faculty diversity, the faculty should be accomplished in teaching as well as leaders in research and/or clinical care. An appropriate research environment and institutional support of research are necessary for pharmacy to exist as an equal partner in the health sciences.

California has some unique problems and needs in pharmacy education. San Diego is the largest metropolitan area in the United States without a public or private school of pharmacy. Our expanding biotechnology industry (third largest in the US) will transition into a pharmaceutical industry, and FDA Good Manufacturing Practices require pharmacists to be on the staff. California has but one State-supported pharmacy school for 36 million people; other states with 4-5 million (e.g., Washington and South Carolina) have two. Bordering states with populations of less than one million (Montana, Idaho and Wyoming) have a School of Pharmacy. The greatest shortages of pharmacists occur in the ethnic and inner city areas and in placing highly skilled pharmacists for settings in which chronic monitoring of therapy is required. It is unlikely that proprietary pharmacy schools will meet these needs since: a) they lack the clinical settings for instruction, and b) their high tuitions restrict admissions to only students with the appropriate financial means. The Los Angeles Times series for the week of May 25, 1999 detailed the unique border problems we have in drug distribution; all of the academic input was coming from Los Angeles and Texas.


Perhaps the best approach to drawing together all of our findings is to quote from one of our committee members, who is not a Health Sciences professional, "...that so many clinical faculty extend themselves in near impossible ways cannot continue, nor can such efforts maintain the UC Health Sciences Schools at a top national level in the 21' century. Moreover, continuing to train students in such conditions does a disservice to the State of California in the long run."

The issues summarized in this report are serious and deserve consideration at the highest levels -in the University. It is not merely the education of our students, which is at stake, but the continued well-being of our citizens. - Many of the issues involve questions in increased funding. There is a perception throughout the UC System, held by many, that the health sciences programs are 'over-funded' and should make do with whatever they currently have. This position does not take into account the deleterious effects of an increasingly competitive market for clinical training sites and the difficulty in attracting promising young academics to our system. If the current situation were to remain static, serious questions would arise concerning the viability of the current size and mission of our program. Thus:

  1. Do we wish to reduce the number of Health Sciences students in our Programs? Would not cuts in enrollment decrease the FTE ratios and result in the loss of more faculty?
  2. Is it possible and desirable in the current political climate to raise the professional fee differential in our Health Sciences Schools?
  3. In the case of the non-M.D. programs, is there any possibility of readjusting the faculty/student ratios to provide more clinical teaching manpower?
  4. Can funds be made available to upgrade the clinical facilities (particularly in the Schools of Dentistry) to provide contemporary equipment for clinical care?
  5. Is it possible to restore faculty positions at UCLA which were lost in the early 1990s and which are negatively impacting student education?
  6. Can the University support the development of a Health Sciences Education Institute to foster multidisciplinary education development and communication?
  7. What can be done in the Health Sciences Programs to attract and retain more students and faculties from underserved populations? The failure to achieve this will lead to inadequate health care in those areas where these groups reside.
  8. How can the University better understand and restore faculty morale in all schools when confronted with cuts in personnel, more patient care pressure, and reduced teaching time?
  9. Does the present University system of education foster good collaboration between clinicians and basic researchers to better translate basic biological discoveries into informed clinical practice?
  10. Does the present array of health sciences educational programs meet the projected needs of California into the 21 " Century?

These are a few but not all of the issues raised by the HSEC. The members of the group this year are unanimous in their belief that, under the present circumstances, it is vital for our work to continue into the future. We will be discussing how the composition and structure of the Committee might best serve the needs of the Senate and the University as a whole. We are pleased to have been able to meet with so many dedicated educators and students and to be able to present to the Senate the fruits of our discussions.

Issues In Developing An
Institute For Health Sciences Education

What are the immediate needs in developing an initial strategic planning process for the Institute?
  1. We should obtain agreement and commitment from each of the health sciences programs that the development of such an Institute is both desirable and achievable within the structure of the entire UC System. This implies that important faculty should be contacted by representatives of the Health Sciences Education Committee and that the idea be discussed with them, for both their approval and suggestions. All that would be asked of them, at this point, is whether the establishment of an Institute for Health Sciences Education and Research should be pursued, to determine its operational and financial viability. Any further details about its exact organization and content would await an assessment of its feasibility.
  2. Who should be contacted at this juncture from within the various programs? We -should contact all the Deans of the Schools and all of the Deans for Education in each program. In addition, the chairs of the Educational Policy Committees should be approached for their opinions and those of their committee members. They, in turn, should consult with their colleagues, who have major responsibility for designing and conducting the various components of the educational curriculum.

Once the academic leaders of health sciences education programs concur with the idea of an Institute, the plan must be thoroughly discussed with the Academic Council and the Office of the President. This enterprise, to be successful, must be regarded as a Universitywide activity, integrating and supporting the educational needs of our entire system. The central idea of the Institute is that, through sharing of ideas and resources, programs throughout the University can be strengthened and costs of educational innovation reduced.

Assuming that the basic idea of the formation of an Institute is acceptable to all parties, what steps should be taken next to implement the idea?

An assessment should be made to identify the basic costs necessary to begin the process of developing an Institute. This should include the costs of.

  1. Space for staff work and meetings.
  2. Administrative Staff (Administrative Analyst, Administrative Assistant), as a starting requirement.
  3. Utilities (lights, telephones, heat, etc.)
  4. Computer capabilities and establishment of an Institute Web-Site.
  5. Bibliographical budget-books, journals, special educational reports.
  6. Consultant fees.
  7. Travel budget for a core planning committee for the Institute.
  8. Necessary furniture and fixtures (if not otherwise available).
  9. Funds for reproduction of materials to be sent to committee members.
  10. Basic office supplies.

Developing a strong rationale for the establishment of the Institute

It is becoming increasingly clear that the education of health sciences professionals is a much more complex and time consuming task than at any time in the past. This complexity arises from a number of factors.

  1. The role of a health care provider has greatly expanded in the current environment of patient needs and expectations. Appropriate health care goes beyond the traditional role of the diagnosis and treatment of illness. It now includes greater emphasis on prevention, patient education, and awareness of efficient use of resources. The health professional is also being asked to demonstrate a working knowledge of ethical issues relating to practice and be sensitive to sociocultural factors as they apply to their patients.
    These new skills frequently must be applied in clinical settings that require maximal time efficiency when examining patients. The integration of all of these factors alongside that of mastery of patho-physiology and therapeutics places an enormous burden of learning and integration upon students and their teachers. It is clear that new methods of demonstration and instruction must be developed in order to effectively help students to learn the knowledge, skills, and attitudes necessary to function effectively and humanly in contemporary clinical environments.
    It is our belief that methods for achieving the integration of these factors may be best accomplished by pooling the experience and creativity of faculty in a network of academic centers. They can join forces in sharing their experiences in curriculum development, student skill assessment, faculty teaching development, and effective use of contemporary educational technology. They should advise on issues of student admission policy and creating social environments that best support health sciences learning. The scope of collaboration must include undergraduate, graduate and post-graduate education. The focus should be both on the design of educational materials and experiences, but also include research into effectiveness of a variety of educational approaches. Health educators realize today that we must not only understand what should be learned, but also what are the most effective techniques and environments of learning. Health education can become in itself a domain of scholarly study and research.
  2. The Institute would be a clearinghouse among the collaborating programs for sharing ideas, educational materials and technological innovations. This would be accomplished by use of a special web-site, periodic colloquial visiting scholar programs, and research support for educational innovation. The Institute could produce its own newsletter, keeping member programs informed about educational issues in the health sciences, both within the UC system and nationally. It is interesting to learn that Harvard University has established in the past two years its own Institute for Medical Education in collaboration with Beth Israel Hospital. There have been conversations with the leaders of the Institute to share ideas between these two major health education centers (and, perhaps, collaboratively develop a national network over time with other institutions). In an era of diminishing support for Academic Health Centers and escalating demands on faculty time, the use of a consortium of health science programs to share their successes and mistakes may invigorate our educational efforts and contribute to the national dialogue about the development of future health providers and researchers.
  3. The Institute would include all health sciences programs throughout the UC system and include programs in Medicine, Nursing, Pharmacy, Dentistry, Veterinary Medicine, Optometry, and Public Health. It would also include the special Medical Science Programs at Berkeley and Riverside. The Institute would be led by a Director and an Associate Director, who would be responsible for developing its educational activities and communicating with faculty throughout the system. They would also be responsible for maintaining contact nationally as it relates to health sciences education and make this information available to the consortium. The Directors would be assisted by a steering committee, which would set programmatic goals and establish managerial and fiscal policy. In addition, there would be an Educational Advisory Committee, which would maintain a flow of information between the Institute and the participating programs. It would assess the work of the Institute as it impacts on the participating programs and suggest new projects, symposia and means of testing teaching innovations. It would be the creative arm of the enterprise and the Steering Committee, the managerial component.


Establishment of a UC Institute for

Health Sciences Education Recommendations

There are many recommendations in the Report, dealing with curriculum design and alteration in AMC management, which are most appropriately dealt with by the various health sciences campuses.

There is much that the UC System as a whole can do to make Health Education more innovative, efficient and effective. Basically, we must begin to view and plan around all AMC programs at UC as part of a unified and integrated system. There are tasks which can and should be left to individual campuses. However, there is a great deal of cooperation and communication between the campuses, -which can and should be supported and expanded. To do so, the following recommendation is presented:

  1. The University should establish an INSTITUTE FOR HEALTH SCIENCES EDUCATION. The purpose of this Institute would be to:
    1. Conduct research on the most effective means of teaching in the health sciences, which reflect both statewide and national innovations;
    2. Ensure the dissemination of the results of such research to key educators on local campuses. This can be done by visits to various programs and through holding workshops at regular intervals for teachers on a Systemwide basis.
    3. Bring together a faculty comprised of 'Regents Scholars' appointed on each campus who would be experts in the field of Medical (and related field) education. Invited resident guest faculty and faculty working within the system would augment these scholars.
    4. Hold a series of semi-annual symposia on critical subjects in Health Sciences Education, (with invited speakers) and publish the proceedings and distribute them to all relevant campuses.
  2. The Institute should establish a web site where there can be electronic sharing of important information relating to Health Education topics. It should facilitate the sharing of curriculum, the development of model curriculum, disseminate bibliographies of important new works in the field, and provide a 'chat site' for educators to mutually develop ideas about teaching and evaluation.
  3. The University should organize model continuing education programs that can reach out to practitioners throughout the State on critical issues of research, clinical care and education. Provide videotapes of such programs for loan or purchase for practitioners who cannot attend.
  4. The University should provide a battery of experts from throughout the system to periodically visit and, give consultation to all programs within our UC system, relating to educational matters: (undergraduate, graduate and post graduate). Experts should periodically examine and evaluate the issue of medical school class size as well as the racial and ethnic composition of the classes in all of the health sciences schools.
  5. The University should develop an outreach program to all UC undergraduate schools to advise on preparation for premedical (and other Health Sciences) requirements. Such an outreach program would educate students about careers in medicine, help design relevant premed curricula which would be based on both biomedical and psychosocial skills and help encourage students from underrepresented segments of the Health Sciences student body to consider careers in Medicine and other helping professions. It would also help course directors to refresh their offerings with contemporary research in the health care and research fields.
  6. The University should devise and conduct research studies within the UC programs on the most effective educational means of learning.
  7. The University should assist all graduates of UC Medical Schools in their quest for lifelong learning by developing and disseminating a newsletter which summarizes the most useful recent research findings that are relevant to changing the modes of clinical care. The production of such a newsletter can be the joint responsibility of several departments within the system. Besides providing useful information, it would be a periodic reminder of the ongoing thrust of biomedical and psychosocial discovery. The University system could also develop a yearly clinical review conference in several areas for graduating practitioners.
  8. The Institute should also serve to assess and advocate for increased financing throughout the system for increased educational funding. It should particularly examine how the move to more community based outpatient sites for clinical learning may necessitate new financial commitments.
  9. Another important function of the Institute should be to examine issues relating to faculty hiring, retention and support throughout the system. It should periodically examine what skills are needed within the faculty to ensure continued excellence of teaching and research. A particular emphasis should be placed on developing more powerful incentives for excellence in teaching and mentoring, particularly in clinical settings.

The Institute would not reside on any one campus but would bring teachers and scholars together at different sites for discussion and learning. They would be linked by an electronic network and teleconferencing.

UC must establish such a greater sense of collaboration and sharing of resources among its various Health Sciences Programs if it is to continue its leadership in this domain of education.

Last Webpage Update: 8/22/13

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