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Presidential address of Association of Professors of Gynecology and Obstetrics
Clinical Articles
Presidential address of Association of Professors of Gynecology and Obstetrics Allan B. Weingold, M.D. Washington, D. C.
It is a significant honor to be recognized by one's peers and to be given the opportunity to lead an organization whose primary goal is the perpetuation of our discipline. It is a particular honor to serve in that role in the twenty-fifth anniversary year of the Association of Professors of Gynecology and Obstetrics, which also represents for me a twenty-fifth anniversary in academic medicine. The goals of my presidential address are limited and simple: to express some aspects of personal philosophy; to summarize the problems we face in medicine, in academic careers, and in our discipline; to review the changes in the Association of Professors of Gynecology and Obstetrics and our specialty in the past 25 years; and to provide some inspirational thoughts about the future. Persons in my position have a problem. While we are medical teachers in that we have taught students for 25 or more years, we are not experts in education. Although we cannot explain it in educational terms, we have developed an instinct for those approaches in medical education that work and those that do not. It is this instinct that makes some of us react so negatively to the suggestions of those who work in the theory rather than the practice of medical education. For example, the concept that in an ideal world, medical education would be a totally integrated and interdisciplinary experience is one that I do not find very convincing. In my experience, integrated teaching is difficult to plan and to mount, expensive, and extremely time-consuming for the organizers, and it is From the Department of Obstetrics and Gynecology, George Washington University School of Medicine. Presented at the Association of Professors of Gynecology and Obstetrics, New Orleans, Louisiana, February 28, 1987. Received for publication April15, 1987; accepted May 19, 1987 Reprint requests: Allan B. Weingold, M.D., The George Washington University Medical Center, 2150 Pennsylvania Ave, N.W., Washington, DC 20037.
confusing for the students who have to grapple simultaneously with the difftrent approaches of a variety of persons and disciplines. Of more importance, it is potentially harmful for departments, since it eliminates their strongest stimulus-the responsibility for their own teaching. Another currently popular concept is that "students should be taught principles rather than facts".' The truth is that both are needed. Principles are pretty dull unless the facts that they tie together are known. It is not exciting to have a solution without a problem. Principles are really exciting only when they help us fit together the various bits of knowledge and experience that float about in our heads and make the whole into an attractive story. We are also told that students should not be taught; it makes them mentally lazy. They should discover their own areas of ignorance and respond appropriately. Perhaps the reason that I find this so hard to accept is my enormous sense of debt and gratitude to the excellent faculty who shared with me the wisdom they had built up through years of experience. I do not think it made me mentally lazy; in fact, I think it opened my mind to all forms of curiosity and adventure. I really enjoy listening to someone who knows his or her subject intimately-and loves it. That teacher can give a particular insight as to how the mind works and what the subject is really about. Let me now review some of the problems that face us in 1987. After World War II biomedical science was able to achieve major advances in the relief of suffering, the rehabilitation of injuries and the prevention of disease and premature death. This success led to an increased demand for medical services and resulted in a perceived shortage of physician manpower. By 1962, the first year of the Association of Professors of Gynecology and Obstetrics, this country was prepared to 799
800
Weingold
October 1987 Am J Obstet Gynecol
Table I. Presentations at meetings of the Association of Professors of Gynecology and Obstetrics 1967 1969 1970 1972 1973 1974 1976 1977
"Medicare and undergraduate education," Dr. John VanS. Maeck "The consumer in medicine," John Mills, Ph.D., Chancellor, Case Western Reserve University "Intradisciplinary specialization," Drs. F. P. Zuspan, D. A. Barron,]. G. Moore, and W. L. Herrmann "HMO's," Drs. P. D. Bruns and]. R. Willson "Medicine and government in Canada," Dr. R. P. Beck (University of Alberta) "Faculty funding," Drs. K. E. Krantz and W. H. Pearse "The education of women in OB/GYN," Drs. E. R. Carrington and M.]. Gray "Medico-legal problems," Dr. K. P. Russell
mobilize for a substantial expansion of its capacity to train health professionals. Academic medical centers produced and applied much of the new biomedical knowledge and helped, in a major way, to fulfill society's medical commitments to its indigent members. In 1987 it appears that society sees a physician glut and has recognized the limits of its ability, or at least its willingness, to accord a protective status to these institutions. Efforts to curb escalating expenditures for the care of elderly persons and indigent persons have resulted in new payment systems that are designed to foster price competition and to eliminate hidden subsidies for teaching institutions? The primary environmental change affecting medical education is an economic one. Teaching hospitals are motivated to cut expenses, increase efficiency, and be more businesslike. Because of decreasing support for research and reduced funding in support of medical education, medical schools are encouraging faculty members to supplement their salaries by an increase in the number of patients they treat. Large-scale purchasers of medical services are seeking to contract with hospitals and physician groups that will provide acceptable quality of services at the lowest cost. These purchasers do not believe that educational costs are their responsibility. The implications for the academic medical centers are ominous inasmuch as they also provide a disproportionately large share of the most sophisticated, intensive, and expensive hospital services. In particular this care is provided to medically indigent persons. Six percent of these hospitals provided 4 7% of the charity care charges and incurred 35% of the bad debts in the country! Obstetric care alone accounted for nearly 25% of all uncompensated hospital charges. In 1983, this amount was $1.7 billion. Regionalization of perinatal care (at least as it involves the medically insured patient) is more difficult because hospitals are encouraged to compete rather than cooperate. Teaching services are having difficulty in the maintenance of the patient base necessary for their mission inasmuch as well-trained alumni now provide, in community hospitals, specialized services that were available
earlier only at academic medical centers. What we, in the academic medical center, produce is a valued commodity, with no proprietary rights to it. It is different from inventing an item at Bell Laboratories, which the company markets and benefits are reaped for 17 years. 3 Our product, the student, resident, fellow, or the results of research, is rapidly translated to patient care in a variety of settings, often to the detriment of the medical center. In addition, the experience students and residents receive on a tertiary in-patient service is composed of chronic and complex care and is generally not related to situations that they will face in practice. Increasingly, with same-day admissions and early discharge, they do not get to see the entire span of medical events. The obvious solution, the development of large affiliated programs with a community hospital base, goes a long way toward solving the numbers problem in student and resident training, but it also disperses and dilutes the educational effort and the continuity of care that is possible in a single-unit health center. And what of the product of our efforts? Students and residents have always been anxious about beginning their medical careers, but these concerns focused more on quality-of-living issues and practice environment. These have been replaced by some very real issues, such as fears of a surplus of physicians, the prospect of competing with professional colleagues and former classmates, the decline of the traditional, solo fee-for-service medical practice, the loss of autonomy from health care institutions, government, and thirdparty payors, and the impact of technological change." Although there has been no perceptible decline in the quality of the credentials presented by applicants entering medical school, the number of applicants has decreased steadily since 1974 and a decline in the quality of the applicant pool should be anticipated. At times like this all of us need to step back from these problems and look for some perspective in dealing with them on the basis of where we have been. I would like to look at "APGO at 25" to remind all of us of the enormous changes that have occurred since the founding of this society.
APGO presidential address 801
Volume 157 Number 4, Part I
Table II. Changes in field of health care National health expenditures Percentage research-development Total number of physicians Obstetrician-gynecologists U.S. medical schools Applicants Women applicants Graduates Education expenditures Federal funding Physician's services for funding Tuition State (mean) Private (mean) Full-time clinical faculty Postgraduate salary (1 yr) Postgraduate women ( 1 yr) Malpractice premium (Washington, D.C.)
The first meeting of the Association of Professors of Gynecology and Obstetrics was held at the PickCongress Hotel in Chicago in 1962, with 175 people in attendance under the leadership of the first president, Roy Holly, M.D. The first five programs focused entirely on curriculum, evaluation, and pedagogy in undergraduate and graduate education. Inevitably, thereafter, the problems of the real world intruded into the program (Table I). These problems have dramatically changed the face of the entire educational enterprise during the past 25 years. Some of these changes are depicted in Table II. The focal points include the real as well as inflationary increases in both total national health costs and the costs of medical education; the increase in the number of medical schools, medical students, clinical faculty, practicing physicians, and specialists in obstetrics and gynecology; the women's movement, with its major impact on medical education; and the steadily decreasing component of educational costs funded by the federal government. From a historical perspective, it is also important to remember that many of these changes occurred in response to predicted needs that were perceived as largely unmet 25 years ago. The accuracy of our predictions was not high. "The Census Bureau projection of 6,400,000 births in 1985 bears specifically on the need for more maternity beds and more medical manpower in this specialty."' The actual number of births in 1985 was 3,747,000. There have been many changes in our discipline in this relatively short time span. "Since there is such a small chance of the survival of an infant under 1,000 gms., (less than 5%), all such fetuses should be classified as abortuses."' Also a word of caution about the excesses of operative delivery when the national cesarean section rate had climbed to 4.8%: "There was
8.1% 7,480 $436 million 48.1% 6.0%
Now $381.2 billion 3.0% 486,000 34,000 127 29,000 (1975 peak 42,000) 35.2% 16,875 $9,000 million 23.5% 35.9%
$498 $1,050 8,750 $2,465 8% $640
$3,959 $13,105 45,300 $21,800 51% $58,000
Then $26.5 billion 4.8% 274,000 14,000 86 15,740
Table III. Innovations and areas of concern in obstetrics-gynecology since 1962 Real-time ultrasound Tocolytics Legalized abortion Laparoscopy In vitro fertilization-embryo transfer Gonadotropin-releasing hormone Amniocentesis-chorionic villus sampling Laser Herpes Pergonal Cryosurgery Acquired immune deficiency syndrome ~-subunit of human chorionic gonadotropin Microsurgery Danocrine Surrogates Fetal monitoring
a time when the excellence of an obstetric service was judged by the scarcity of cesarean sections performed. There has been a tremendous shift in viewpoint regarding the validity of this criterion resulting in the current increased rates." 5 One needs only to reflect on the fact that none of the techniques, therapies, or clinical diagnoses depicted in Table III were clinically relevant 25 years ago. Accurate assessments of the future for today's students do not exist because of the difficulty of predicting changes in health care utilization, technology, and patterns of care provision. The changing environment of medicine presents both threats and opportunities for young physicians. The very nature of technological progress makes the role of technology less certain. Some advances may reduce the demand for the services of a particular specialty if the technology can be used
802
Weingold
by nonphysicians. Others may require more physician involvement because of the need for professional sophistication in their use. 4 Other advances transform the very nature of a specialty inasmuch as we are now seeing the so-called noninvasive cardiologic techniques impacting on the field of cardiovascular surgery. In turn, magnetic resonance imaging, by accurately visualizing coronary artery occlusions, could obviate catheterization skills learned in current cardiology fellowships. This is a form of technological vulnerability. The demographics of health care are changing. Visits to the physician increase as the patient ages. Women, after the age of 17, consistently have a greater number of visits to the physician per year. In a population that is rapidly aging and one in which women will make up a decided majority of elderly persons, these trends will strongly influence the nature of our practices and how we train for the specialty. The changing structure of health care is already visible in a variety of "turf disputes" resulting in a decline of collegiality within the physician community. 6 Pressure will increase to limit the growth in physician supply from both within and outside the profession. Reduction in the size of medical school classes, in the face of significant fixed costs, is not associated with a parallel decrease in the cost of education. Smaller class sizes will inevitably result in higher tuitions; this will further discourage economically disadvantaged students from applying for admission to medical school. Closing medical schools is a solution, but the list of volunteers is small. There will also be a move to reduce the number of graduate medical education training positions. This will intensify the competition for residents' positions. Despite all these potentially adverse consequences to
October 1987 Am J Obstet Gynecol
individual physicians, I believe that innovations in medical education, technology, and the organization of medical practice will continue to improve the ability of physicians to provide high-quality medical care to their patients. After years of change driven by biomedical discoveries emanating from the academic medical centers, there is a new site of innovation within the delivery system itself and those in the forefront are not academicians.• It is important that, as we translated what we have learned in the laboratory to the delivery system in the past, we must now take what is being learned in the marketplace and bring it back to the classroom. Each physician must understand the changing horizon of medicine and be able to take whatever steps are necessary to remain professionally flexible. This capacity needs to be taught. The challenge lies with those of us who teach our specialty to demonstrate that flexibility and to identify and train the leaders for the future of medical practice from among the current medical students. REFERENCES I. Physicians for the twenty-first century (the GPEP report).
2. 3.
4. 5. 6.
Washington DC: American Association of Medical Colleges, 1984. Medical education: institutions, characteristics and program. Washington DC: American Association of Medical Colleges, 1986. Morgan WL. The environment for medical education. In: Proceedings of the American Association of Medical Colleges national invitational conference on clinical education, Washington DC, Sept 5-6, 1985:46. Health care in transition-consequences for young physicians (council report). J AMA 1986;256:3384. PritchardJA, MacDonald PC, eds. Williams' obstetrics. 13th ed. New York: Appleton-Century-Crofts 1963:4, 1004. Medical education-back to the future. ACOG newsletter 1987 Jan 31:1.
Presidential address of Association of Professors of Gynecology and Obstetrics Allan B. Weingold, M.D. Washington, D. C.
It is a significant honor to be recognized by one's peers and to be given the opportunity to lead an organization whose primary goal is the perpetuation of our discipline. It is a particular honor to serve in that role in the twenty-fifth anniversary year of the Association of Professors of Gynecology and Obstetrics, which also represents for me a twenty-fifth anniversary in academic medicine. The goals of my presidential address are limited and simple: to express some aspects of personal philosophy; to summarize the problems we face in medicine, in academic careers, and in our discipline; to review the changes in the Association of Professors of Gynecology and Obstetrics and our specialty in the past 25 years; and to provide some inspirational thoughts about the future. Persons in my position have a problem. While we are medical teachers in that we have taught students for 25 or more years, we are not experts in education. Although we cannot explain it in educational terms, we have developed an instinct for those approaches in medical education that work and those that do not. It is this instinct that makes some of us react so negatively to the suggestions of those who work in the theory rather than the practice of medical education. For example, the concept that in an ideal world, medical education would be a totally integrated and interdisciplinary experience is one that I do not find very convincing. In my experience, integrated teaching is difficult to plan and to mount, expensive, and extremely time-consuming for the organizers, and it is From the Department of Obstetrics and Gynecology, George Washington University School of Medicine. Presented at the Association of Professors of Gynecology and Obstetrics, New Orleans, Louisiana, February 28, 1987. Received for publication April15, 1987; accepted May 19, 1987 Reprint requests: Allan B. Weingold, M.D., The George Washington University Medical Center, 2150 Pennsylvania Ave, N.W., Washington, DC 20037.
confusing for the students who have to grapple simultaneously with the difftrent approaches of a variety of persons and disciplines. Of more importance, it is potentially harmful for departments, since it eliminates their strongest stimulus-the responsibility for their own teaching. Another currently popular concept is that "students should be taught principles rather than facts".' The truth is that both are needed. Principles are pretty dull unless the facts that they tie together are known. It is not exciting to have a solution without a problem. Principles are really exciting only when they help us fit together the various bits of knowledge and experience that float about in our heads and make the whole into an attractive story. We are also told that students should not be taught; it makes them mentally lazy. They should discover their own areas of ignorance and respond appropriately. Perhaps the reason that I find this so hard to accept is my enormous sense of debt and gratitude to the excellent faculty who shared with me the wisdom they had built up through years of experience. I do not think it made me mentally lazy; in fact, I think it opened my mind to all forms of curiosity and adventure. I really enjoy listening to someone who knows his or her subject intimately-and loves it. That teacher can give a particular insight as to how the mind works and what the subject is really about. Let me now review some of the problems that face us in 1987. After World War II biomedical science was able to achieve major advances in the relief of suffering, the rehabilitation of injuries and the prevention of disease and premature death. This success led to an increased demand for medical services and resulted in a perceived shortage of physician manpower. By 1962, the first year of the Association of Professors of Gynecology and Obstetrics, this country was prepared to 799
800
Weingold
October 1987 Am J Obstet Gynecol
Table I. Presentations at meetings of the Association of Professors of Gynecology and Obstetrics 1967 1969 1970 1972 1973 1974 1976 1977
"Medicare and undergraduate education," Dr. John VanS. Maeck "The consumer in medicine," John Mills, Ph.D., Chancellor, Case Western Reserve University "Intradisciplinary specialization," Drs. F. P. Zuspan, D. A. Barron,]. G. Moore, and W. L. Herrmann "HMO's," Drs. P. D. Bruns and]. R. Willson "Medicine and government in Canada," Dr. R. P. Beck (University of Alberta) "Faculty funding," Drs. K. E. Krantz and W. H. Pearse "The education of women in OB/GYN," Drs. E. R. Carrington and M.]. Gray "Medico-legal problems," Dr. K. P. Russell
mobilize for a substantial expansion of its capacity to train health professionals. Academic medical centers produced and applied much of the new biomedical knowledge and helped, in a major way, to fulfill society's medical commitments to its indigent members. In 1987 it appears that society sees a physician glut and has recognized the limits of its ability, or at least its willingness, to accord a protective status to these institutions. Efforts to curb escalating expenditures for the care of elderly persons and indigent persons have resulted in new payment systems that are designed to foster price competition and to eliminate hidden subsidies for teaching institutions? The primary environmental change affecting medical education is an economic one. Teaching hospitals are motivated to cut expenses, increase efficiency, and be more businesslike. Because of decreasing support for research and reduced funding in support of medical education, medical schools are encouraging faculty members to supplement their salaries by an increase in the number of patients they treat. Large-scale purchasers of medical services are seeking to contract with hospitals and physician groups that will provide acceptable quality of services at the lowest cost. These purchasers do not believe that educational costs are their responsibility. The implications for the academic medical centers are ominous inasmuch as they also provide a disproportionately large share of the most sophisticated, intensive, and expensive hospital services. In particular this care is provided to medically indigent persons. Six percent of these hospitals provided 4 7% of the charity care charges and incurred 35% of the bad debts in the country! Obstetric care alone accounted for nearly 25% of all uncompensated hospital charges. In 1983, this amount was $1.7 billion. Regionalization of perinatal care (at least as it involves the medically insured patient) is more difficult because hospitals are encouraged to compete rather than cooperate. Teaching services are having difficulty in the maintenance of the patient base necessary for their mission inasmuch as well-trained alumni now provide, in community hospitals, specialized services that were available
earlier only at academic medical centers. What we, in the academic medical center, produce is a valued commodity, with no proprietary rights to it. It is different from inventing an item at Bell Laboratories, which the company markets and benefits are reaped for 17 years. 3 Our product, the student, resident, fellow, or the results of research, is rapidly translated to patient care in a variety of settings, often to the detriment of the medical center. In addition, the experience students and residents receive on a tertiary in-patient service is composed of chronic and complex care and is generally not related to situations that they will face in practice. Increasingly, with same-day admissions and early discharge, they do not get to see the entire span of medical events. The obvious solution, the development of large affiliated programs with a community hospital base, goes a long way toward solving the numbers problem in student and resident training, but it also disperses and dilutes the educational effort and the continuity of care that is possible in a single-unit health center. And what of the product of our efforts? Students and residents have always been anxious about beginning their medical careers, but these concerns focused more on quality-of-living issues and practice environment. These have been replaced by some very real issues, such as fears of a surplus of physicians, the prospect of competing with professional colleagues and former classmates, the decline of the traditional, solo fee-for-service medical practice, the loss of autonomy from health care institutions, government, and thirdparty payors, and the impact of technological change." Although there has been no perceptible decline in the quality of the credentials presented by applicants entering medical school, the number of applicants has decreased steadily since 1974 and a decline in the quality of the applicant pool should be anticipated. At times like this all of us need to step back from these problems and look for some perspective in dealing with them on the basis of where we have been. I would like to look at "APGO at 25" to remind all of us of the enormous changes that have occurred since the founding of this society.
APGO presidential address 801
Volume 157 Number 4, Part I
Table II. Changes in field of health care National health expenditures Percentage research-development Total number of physicians Obstetrician-gynecologists U.S. medical schools Applicants Women applicants Graduates Education expenditures Federal funding Physician's services for funding Tuition State (mean) Private (mean) Full-time clinical faculty Postgraduate salary (1 yr) Postgraduate women ( 1 yr) Malpractice premium (Washington, D.C.)
The first meeting of the Association of Professors of Gynecology and Obstetrics was held at the PickCongress Hotel in Chicago in 1962, with 175 people in attendance under the leadership of the first president, Roy Holly, M.D. The first five programs focused entirely on curriculum, evaluation, and pedagogy in undergraduate and graduate education. Inevitably, thereafter, the problems of the real world intruded into the program (Table I). These problems have dramatically changed the face of the entire educational enterprise during the past 25 years. Some of these changes are depicted in Table II. The focal points include the real as well as inflationary increases in both total national health costs and the costs of medical education; the increase in the number of medical schools, medical students, clinical faculty, practicing physicians, and specialists in obstetrics and gynecology; the women's movement, with its major impact on medical education; and the steadily decreasing component of educational costs funded by the federal government. From a historical perspective, it is also important to remember that many of these changes occurred in response to predicted needs that were perceived as largely unmet 25 years ago. The accuracy of our predictions was not high. "The Census Bureau projection of 6,400,000 births in 1985 bears specifically on the need for more maternity beds and more medical manpower in this specialty."' The actual number of births in 1985 was 3,747,000. There have been many changes in our discipline in this relatively short time span. "Since there is such a small chance of the survival of an infant under 1,000 gms., (less than 5%), all such fetuses should be classified as abortuses."' Also a word of caution about the excesses of operative delivery when the national cesarean section rate had climbed to 4.8%: "There was
8.1% 7,480 $436 million 48.1% 6.0%
Now $381.2 billion 3.0% 486,000 34,000 127 29,000 (1975 peak 42,000) 35.2% 16,875 $9,000 million 23.5% 35.9%
$498 $1,050 8,750 $2,465 8% $640
$3,959 $13,105 45,300 $21,800 51% $58,000
Then $26.5 billion 4.8% 274,000 14,000 86 15,740
Table III. Innovations and areas of concern in obstetrics-gynecology since 1962 Real-time ultrasound Tocolytics Legalized abortion Laparoscopy In vitro fertilization-embryo transfer Gonadotropin-releasing hormone Amniocentesis-chorionic villus sampling Laser Herpes Pergonal Cryosurgery Acquired immune deficiency syndrome ~-subunit of human chorionic gonadotropin Microsurgery Danocrine Surrogates Fetal monitoring
a time when the excellence of an obstetric service was judged by the scarcity of cesarean sections performed. There has been a tremendous shift in viewpoint regarding the validity of this criterion resulting in the current increased rates." 5 One needs only to reflect on the fact that none of the techniques, therapies, or clinical diagnoses depicted in Table III were clinically relevant 25 years ago. Accurate assessments of the future for today's students do not exist because of the difficulty of predicting changes in health care utilization, technology, and patterns of care provision. The changing environment of medicine presents both threats and opportunities for young physicians. The very nature of technological progress makes the role of technology less certain. Some advances may reduce the demand for the services of a particular specialty if the technology can be used
802
Weingold
by nonphysicians. Others may require more physician involvement because of the need for professional sophistication in their use. 4 Other advances transform the very nature of a specialty inasmuch as we are now seeing the so-called noninvasive cardiologic techniques impacting on the field of cardiovascular surgery. In turn, magnetic resonance imaging, by accurately visualizing coronary artery occlusions, could obviate catheterization skills learned in current cardiology fellowships. This is a form of technological vulnerability. The demographics of health care are changing. Visits to the physician increase as the patient ages. Women, after the age of 17, consistently have a greater number of visits to the physician per year. In a population that is rapidly aging and one in which women will make up a decided majority of elderly persons, these trends will strongly influence the nature of our practices and how we train for the specialty. The changing structure of health care is already visible in a variety of "turf disputes" resulting in a decline of collegiality within the physician community. 6 Pressure will increase to limit the growth in physician supply from both within and outside the profession. Reduction in the size of medical school classes, in the face of significant fixed costs, is not associated with a parallel decrease in the cost of education. Smaller class sizes will inevitably result in higher tuitions; this will further discourage economically disadvantaged students from applying for admission to medical school. Closing medical schools is a solution, but the list of volunteers is small. There will also be a move to reduce the number of graduate medical education training positions. This will intensify the competition for residents' positions. Despite all these potentially adverse consequences to
October 1987 Am J Obstet Gynecol
individual physicians, I believe that innovations in medical education, technology, and the organization of medical practice will continue to improve the ability of physicians to provide high-quality medical care to their patients. After years of change driven by biomedical discoveries emanating from the academic medical centers, there is a new site of innovation within the delivery system itself and those in the forefront are not academicians.• It is important that, as we translated what we have learned in the laboratory to the delivery system in the past, we must now take what is being learned in the marketplace and bring it back to the classroom. Each physician must understand the changing horizon of medicine and be able to take whatever steps are necessary to remain professionally flexible. This capacity needs to be taught. The challenge lies with those of us who teach our specialty to demonstrate that flexibility and to identify and train the leaders for the future of medical practice from among the current medical students. REFERENCES I. Physicians for the twenty-first century (the GPEP report).
2. 3.
4. 5. 6.
Washington DC: American Association of Medical Colleges, 1984. Medical education: institutions, characteristics and program. Washington DC: American Association of Medical Colleges, 1986. Morgan WL. The environment for medical education. In: Proceedings of the American Association of Medical Colleges national invitational conference on clinical education, Washington DC, Sept 5-6, 1985:46. Health care in transition-consequences for young physicians (council report). J AMA 1986;256:3384. PritchardJA, MacDonald PC, eds. Williams' obstetrics. 13th ed. New York: Appleton-Century-Crofts 1963:4, 1004. Medical education-back to the future. ACOG newsletter 1987 Jan 31:1.