Table Of ContentThe Medical School's Mission and the
Population's Health
Kerr L. White Julia E. Connelly
Editors
The Medical School's
Mission and the
Population's Health
Medical Education in Canada, The United
Kingdom, The United States, and Australia
Proceedings of a Conference Sponsored by
The Royal Society of Medicine Foundation, Inc., and
The Josiah Macy Jr. Foundation
December 9-12, 1990, Turnberry Isle, Florida
With 20 Illustrations
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
Kerr L. White Julia E. Connelly
(Retired Deputy Director for Health Associate Professor of Medicine
Sciences, The Rockefeller Foundation, University of Virginia Medical Center
New York) Charlottesville, V A 22908 USA
2401 Old Ivy Road, #1410
Charlottesville, V A 22901-3470 USA
Library of Congress Cataloging-in-Publication Data
The Medical school's mission and the population's health: medical
education in Canada, the United Kingdom, the United States, and
Australia / Kerr L. White, Julia E. Connelly, editors.
p. cm.
Based on a meeting organized by the Royal Society of Medicine
Foundation and the Josiah Macy, Jr. Foundation, Dec. 9-12, 1990 at
Turnberry Isle, Fla.
Includes bibliographical references and index.
ISBN -13:978-0-387-97772-0
1. Medical education-Congresses. 2. Medical education policy
-Congresses. 3. Public health-Congresses. 1. White, Kerr L.
II. Connelly, Julia E. III. Royal Society of Medicine Foundation.
IV. Josiah Macy, Jr. Foundation.
[DNLM: 1. Public Health-education-Australia-congresses.
2. Public Health-education-Canada-congresses. 3. Public Health
-education-Great Britain-congresses. 4. Public Health-education-
-United States-congresses. 5. Schools, Medical-Australia-
-congresses. 6. Schools, Medical-Canada-congresses. 7. Schools,
Medical-Great Britain-congresses. 8. Schools, Medical-United
States-congresses. W 19 M4913 1990]
R735.A2M43 1992
61O'.71'I-dc20
DNLM/DLC
for Library of Congress 91-5154
Printed on acid-free paper.
© 1992 Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1992
All rights reserved. This work may not be translated or copied in whole or in part without
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ISBN-13:978-0-387-97772-0 e-ISBN-13:978-1-4613-9189-0
DOl: 10.1007/978-1-4613-9189-0
Foreword
Medical schools exist as part of a complex educational and health care sys
tem with affiliations to universities, teaching hospitals, outpatient clinics,
students, and communities.
Those of us who serve as trustees and volunteers on boards and commit
tees of medical schools carry obvious responsibilities for the performance
of the institution with regard to those affiliations, including those that relate
to the community.
By what criteria, and by what standards, do we as trustees assess that
performance? For trustees of medical schools, I suggest that the most im
portant criteria are those concerned with the purpose for which the school
was originally established and those that relate to the community that sup
ports it and is served by it.
For a medical school performance criteria should be defined in a statement
of purpose: the "mission" of the school. This mission statement should pro
vide trustees with direction on such vital matters as the following: What does
the medical school seek to accomplish? Whom does it serve? Where is it
going? What is the relationship to the geographic region or other community
that it may seek to serve?
Such questions are stated more easily than they are answered, but they
should be asked. For trustees who are responsible for the education of stu
dents, the management of faculty, and the stewardship of funds they are a
matter of serious concern.
Is there a "community" or "population" to be served by the medical school?
If so, how is it to be defined? No doubt, as an educational institution, the
medical school is concerned with the education and training of its students.
At the same time, as part of the health care system, is the school also to be
charged with any responsibility for understanding and meeting the health
care needs of the population or its "community"?
This volume is the outcome of a meeting organized by the Royal Society
of Medicine Foundation and the Josiah Macy Jr. Foundation to discuss that
question. Those who participated had, for the most part, already concluded
that some responsibility does exist. They came together, therefore, to ex-
v
vi Foreword
amine how medical schools in the United States, United Kingdom, Canada,
and Australia can profit from each other's experience in organizing medical
education, so that faculty and students recognize more fully their respon
sibility for understanding and meeting the health needs of the community.
The 37 participants from the four countries represented perspectives in med
ical education, clinical practice, epidemiology, and government.
In their planning, the organizers of the meeting were guided by a series
of questions they believed to be relevant in all four countries. How should
physicians be educated to respond most effectively to the anticipated health
care needs of the population as well as to the needs of individual patients?
To what extent is the "social contract of medicine" at odds with or in har
mony with the value of diversity in medical education? How do medical
schools determine their collective responsibilities and activities? How do
medical schools individually and collectively view their obligations for the
health of the public? To what extent can medical schools be held accountable
for critical problems in health care (e.g., escalating costs, overspecializa
tion, accessibility), and how should they respond when a community is beset
by huge problems (an epidemic such as AIDS) and a need to find a system
of health care that will provide coverage for all its citizens?
I was delighted to have participated, as President of The Royal Society
of Medicine Foundation, in the lively discussion of the excellent papers and
critiques presented at the meeting. We commend this volume to you as an
important contribution to a vital part of the national debate on health care
policy. Hopefully, it will assist you in framing your own questions, or, at
least, shaping your beliefs as to the role and mission of the medical school
in contributing to the health of the community.
Arthur J. Mahon
President
The Royal Society of Medicine Foundation
Preface
William G. O'Reilly, Executive Director of the Royal Society of Medicine
Foundation, Inc., New York (the North American arm of the Royal Society
of Medicine), and Thomas H. Meikle, Jr., M.D., President of the Josiah
Macy Jr. Foundation, New York, conceived the idea for the Conference
resulting in this volume; the latter Foundation financed it. The two sponsors
perceived urgent problems facing medical schools in four countries that have
similar approaches to medical education, research, and patient care. In their
view the present situation warranted an exploration of common themes un
derlying the malaise besetting medical educators in these countries. Of greater
importance was the prospect of collaborating in the search for fundamental
changes needed in the preparation of physicians to cope with society's health
problems. The Planning Committee for the Conference consisted of
Mutya San Agustin David S. Greer David H.H. Metcalfe
Sir Douglas Black Thomas S. Inui Victor R. Neufeld
Sir Christopher Booth Lionel E. McLeod William G. O'Reilly
Julia E. Connelly Thomas H. Meikle, Jr. Robert S. Spasoff
Kerr L. White (Chair)
To generate fruitful discussion during the Conference, this Committee,
meeting in June 1989, prepared a statement of its principal objectives. These
included the need to develop strategies for expanding the medical school's
mission to embrace the population perspective, in addition to the biomedical
and individual patient-physician perspectives that now dominate most of
Western medical education. To this end the Planning Committee drafted five
recommendations. In addition to these recommendations, the statement of
objectives included possible mechanisms for ensuring their enforcement
through examinations, certification, accreditation, and licensure. Such mea
sures should reassure the public that medical schools are indeed being re
sponsive to concerns about its health status and health services. Promul
gation of a mission statement by each medical school should relate the faculty's
vii
Vlll Preface
educational, research, and patient care commitments to the present and pro
jected health needs of the populations they serve, and should define the
population-based competencies required to accomplish the mission.
The Planning Committee selected the authors and participants; all the first
choices accepted. Papers and topics were chosen on the basis of the five
possible recommendations drafted by the Committee. The authors and topics
selected for the Conference were designed to provide theoretical discussions,
illustrative data, and practical examples of approaches to meeting the pop
ulation's health needs as reflected in the five draft recommendations. The
authors' outlines for the papers were reviewed by all members of the Plan
ning Committee and comments returned to them; the first drafts of the full
papers were similarly reviewed. Final versions of all the papers, together
with three additional written discussions, were circulated to all participants
three weeks prior to the meeting. These arrangements assured ample time
for informed debate by the 37 participants from the four countries over the
four days of the Conference at Turnberry Isle, December 9-12, 1990.
Several authors revised their papers slightly following the meeting and we
have edited them by removing most laudatory and redundant passages,
maintaining reasonable consistency of style, and using American spelling.
The basic messages, together with the three discussants' comments for each
contribution, should have survived intact. From reports prepared by eight
rapporteurs the editors have distilled, without attribution, additional com
ments on the issues raised.
The final sets of definitions and recommendations reflect a strong con
sensus among the Conference Participants; not everyone will agree with every
element of each statement but as a body they all endorse the general thrust
of the ideas recounted in Chapter 9. If these ideas generate further debate
within each of the four countries, and, more importantly, within individual
medical schools, this exercise will have achieved its objectives.
Timely cooperation by everyone enabled the editors to prepare the manu
scripts for rapid pUblication. With this and other tasks William O'Reilly,
his assistant Betty Chase, and Julia E. Connelly's assistant Dale Vander
voort, provided most effective support. We are grateful to all of them, as
well as to our colleagues in this endeavor. We trust our collective efforts
will contribute to an international debate about how, not whether, medical
education must change.
Kerr L. White
Julia E. Connelly
Contents
Foreword-Arthur J. Mahon ................................ v
Preface .................................................. vii
Contributors .............................................. xi
1 Redefining the Mission of the Medical School
Kerr L. White and Julia E. Connelly
Discussion: David S. Greer. John D. Hamilton. and
David A. Shaw
2 The Social Contract and the Medical School's Responsibilities. . 23
Thomas S. I nui
Discussion: David Axelrod. Sir Christopher Booth. and
Ian R. McWhinney
3 Measuring the Burden of Illness in General Populations 60
Michael G. Marmot and Anthony B. Zwi
Discussion: Sir Douglas Black, Robert A. Spasoff. and
Thomas S. I nui
4 The Potential and Organization of Health Intelligence Units 113
Victor R. Neufeld and Robert A. Spasoff
Discussion: Lord Butterfield, Harry S. Jonas. and
Lionel E. McLeod
5 Population-Based Medicine: A Case Study from a Traditional
School ............................................... 132
Mutya San Agustin
ix
x Contents
Discussion: Sir David Innes Williams, Arthur Kaufman, and
Mamoru Watanabe
6 A Community and Population-Oriented Medical School:
Newcastle, Australia .................................... 164
John D. Hamilton
Discussion: Harvey Barkun, George I. Lythcott, and
David H.H. Metcalfe
7 Essential Institutional Competencies for Population-Based
Education ............................................. 208
David H.H. Metcalfe
Discussion: Roger J. Bulger, Victor R. Neufeld, and
Peter Richards
8 Essential Population-Based Competencies for Undergraduate and
Postgraduate Medical Students ............................ 234
Robert D. Cohen
Discussion: Jo Ivey Boufford, Paula L. Stillman, and
John Wade
9 Balancing Perspectives .................................. 257
Kerr L. White and Julia E. Connelly
Conference Participants ..................................... 267
Index ................................................... 271
Contributors
ROBERT D. COHEN, M.D. Professor of Medicine, London Hospital Medical
College, University of London, Whitechapel, London EI IBB, England
JOHN D. HAMILTON, M.D. Dean and Professor of Medicine, Rankin Drive,
University of Newcastle, Newcastle, NSW 2308, Australia
THOMAS S. INUI, M.D. Professor and Head, General Internal Medicine and
Professor of Health Services, School of Medicine, 105A Harborview Hall, Uni
versity of Washington, Seattle, WA 98104, USA
MICHAEL G. MARMOT, M.B., Ph.D. Professor of Community Medicine, 66-
72 Gower Street, University College and Middlesex School of Medicine, London
WCIE 6EA, England
DAVID H.H. METCALFE, M.B., B.S. Professor and Chairman, Department of
General Practice, Rusholme Health Centre, Walmer Street, University of Manch
ester Medical School, Manchester M14 5NP, England
VICTOR R. NEUFELD, M.D. Director, Centre for International Health and Pro
fessor of Medicine and Clinical Epidemiology, HSC-3N44B McMaster Univer
sity, Hamilton, Ontario L8N 3Z5, Canada
MUTYA SAN AGUSTIN, M.D. Director, Department of Ambulatory Medicine,
North Central Bronx Hospital, 3424 Kossuth Street, Room 4M-08, Montefiore
Medical Center, Bronx, NY 10467, USA
ROBERT A. SPASOFF, M.D. Professor and Chairman, Department of Epide
miology and Community Medicine, 451 Smythe Road, University of Ottawa,
Ottawa, Ontario KIH 8M5 Canada
ANTHONY B. ZWI, M.B., Ch.B. Department of Epidemiology and Public Health,
66-72 Gower Street, University College and Middlesex School of Medicine, Lon
don WCIE 6EA, England. Present address: London School of Hygiene, Keppel
Street, London WCIE 7HT, England
xi
