107

IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. BmE-22, NO. 2, MARCH 1975

Current

Issues in Biomedical Engineering RICHARD J. JOHNS,

INTRODUCTION DURING the past decade biomedical engineering has matured as a profession, and its diversity has been increasingly recognized. At the same time the environment external to biomedical engineering has changed rapidly. It has changed politically, socially, and economically. It is the thesis of this essay that biomedical engineering must recognize these external changes and define our goals and objectives in a fashion consonant with and responsive to these changes. To be unresponsive to environmiental changes is to invite the fate of the dinosaur-only our fossilized remains will mark our existence. It makes little difference whether the unresponsiveness is through ignorance, inertia, or obstinacy; the ultimate result will be the same. It is hoped that this discussion will provide some insight into the more powerful and pressing external forces, for awareness is the first step in solving any problem. It is not claimed that specific solutions will be prescribed. Although there is a commonality in the external forces, it is unlikely that any single response (or set of responses) would be universally applicable. Indeed, we are all sufficiently inexperienced in coping rith these forces that a diversity of responses should be encouraged. While the foregoing remarks apply broadly to biomedical engineering, they are especially relevant to the educational aspects for two reasons. First, there is a lag of several years between the formal educational process and its use by the student. Thus, it is important that the educational system not only recognize environmental changes, but attempt to anticipate them. Second, since the external world is changing rapidly and the ability of educators to predict the future is imperfect, it is important to prepare students to be able to cope with change, to be adaptable. What, then, should be the objectives of biomedical engineering and its educational basis? What are the forces at work in the external environment to which biomedical engineering should be responsive? These questions imply that there should be some functional relationship between the educational program in the external environment, an implication that is not universally accepted. It must be acknowledged from the outset that there are at least two contrary viewpoints, views which do not even accept the premises upon which my argumnents are based. Without any attempt at fairness, these may be stated as follows: There are those who believe that education at the uniManuscript received October 4, 1974; revised October 20, 1974. The atuthor is with the Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Md. 21218.

Education

MEMBER, IEEE

versity level has as its sole objective the communication of the fruits of past, present, and personal scholarship to interested students. They hold that insulation from the world and its problems is beneficial to the achievement of this objective. This argument is self-consistent ancd is a comfortable view for a scholar to hold. Although this is acknowledged to be an important objective for universities, it is not, I submit, the sole objective of the university educational system. Pragmatically speaking, universities, if they are to enjoy public support, cannot stand aloof from the public's problems. It should be noted in this regard that so-called private universities rely heavily upon the support of the public through philanthropy, tuition charges, as well as direct benefit from public-supported agencies. A second view is that universities have always taught the immutable truths which are valid for all times, and that a well-prepared student should be able to solve any applied problem starting from first principles. Certainly a thorough grounding in fundamentals is an essential basis for problem-solvinig; however, it should be viewed as necessary, but not sufficient. The student should be provided an opportunity to utilize his understanding of these fundamentals by solving real problems. Unfortunately, many of those who are most vocal about the primacy of fundamentals extend their viewpoint to regard the acquisition of problem-solving skills as "professionalism." which they feel is akin to educating tradesman. Implicit in the followinig discussion is the notion that biomedical engineering and its educational programs should be responsive to external needs. Those who hold to the contrary will not find the arguments persuasive.

DEFINITION Manx conflicting opinions concerning biomedical engineering can be traced to disagreements about its definition. Furthermore, there are disputes about the hierarchical relationships between biomedical engineering, bioengineering, and clinical (or medical) engineering. For the purposes of this discussion, these terms are defined as follows: Bioimedical engineering is considered to be the most inclusive term and is defined as that branch of applied science which is concerned with solving and understanding problems in biology or medicinie using principles, methods, and approaches drawn from engineering science and technology. Bioengineering is that area of biomedical engineerinig concerned with the biological, non-mledical aspects. Clinical engineering and mledical engineering are considered to be synonymous (although fine distinctions can

IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, MARCH 1975

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TABLE I SPECTRUM OF BIOMEDICAL ENGINEERING

Area

Example

Walsh functions representing cardiovascular waveforms Neuroendocrine control of cardiac Basic BME Science output Microflow probe for posterior pituitary Biological Applications On-line cardiac output monitonng Clinical Research Applications Intensive care cardiac monitoring Clinical Practice Health Care Systems Applications Communications support emergency care

Theoretical

Research

Activity Research &

Development

Operations

X X X X

X X X X

X

X X X X X

be drawn) and relate to that area of biomedical engineer- are gainfully employed and are undertaking these educaing concerned with the clinical aspects including health tional programs at a personal economic sacrifice as well as at an expenditure of intellectual effort. care delivery, clinical care, and clinical investigation. This force is acting in a positive way upon undergradSCOPE uate, masters, and doctoral programs in biomedical engiImplicit in the definition of biomedical engineering is neering through increasing enrollment. Federal support. Many biomedical engineering graduate its broad scope. As indicated in Table I, it ranges from theoretical, non-experimental undertakings to state-of- programs were developed in the era of generous federal the-art applications. It can encompass research, develop- support to graduate students-support directed to student ment, implementation, and operation. It is also apparent tuition and stipend payments as well as to institutional from the examples that this spectrum is continuous and support of faculty and staff salaries. These halcyon days that sharp demarcations cannot be drawn. For example, have passed. This type of support is rapidly being phased certain analytic methods or devices may be of equal im- out, and there is no evidence that there is interest in the portance to basic biological investigations and to patient executive or legislative branches in restoring this kind of program support. care. Alternative programs of direct student support for The major conclusion to be drawn from an educational standpoint is that biomedical engineering is broad both graduate education are in disarray. All indications suggest in its biomedical and in its engineering components. Ac- these will be meagre at best and will do little to compensate cordingly, it is unlikely that any single academic program for the loss of federally supported training programs. This force has a profound negative effect on the grador any single track can cover the full scope of its academic content. Furthermore, it is unlikely that any single person uate programs which had come to rely on that resourcecan acquire expertise which encompasses the entire field. Alternative methods of supporting these educational pro. grams must be developed. It is not sufficient to stand by WHAT ARE THE FORCES? in the hope that federal support will be restored, for it is There are positive externpl forces, forces which en- unlikely that this policy decision will be reversed either courage a given course of action, and there are negative by a change in administration or by organized political forces, forces which deter certain actions. No attempt is action by the academic community. made to catalogue all the forces. The focus is on those Quantitative biology and mnedicine. Biology and medicine forces which seem especially potent in their effects on for several decades have been quantitative in their apbiomedical engineering education. This selection is ad- proach to their biochemical and biophysical problems. mittedly subject to personal, institutional, and geographic More recently they have become quantitative in their apbiases. Other forces may be regarded as more important proach to physiological problems in health and disease. The methods of engineering, especially those used in from other points of view. to educaThe most analyzing complex systems, are playing an increasingly Student interest. crucial input any in role in data acquisition, data analysis, hypothethe interest bioimportant tional endeavor is the student. Here, medical engineering is expanding in the face of declining sis formulation, and in the understanding of the fundainterest in other engineering disciplines. At the under- mental nature of the biomedical problem. As a consegraduate level this reflects their idealistic focus on personal quence, there is a demand for education in these areas service as well as realism in their assessment of more con- as an integral part of undergraduate and graduate educastricted employment opportunities in other engineering tion in the life sciences as well as in premedical and medical areas. Similar forces appear to be at work on practicing education. This is a need which can best be filled by speengineers, for they, too, in increasing numbers are express- cially tailored course offerings, and biomedical engineering an interest in biomedical engineering, especiallv in ing educational programs are uniquelv qualified to prothe clinical aspects. It would be cynical to suggest that vide them. The foregoing forces apply primarily to the more basic their motivation is economic, for most of these engineers

JOHNS: CURRENT

ISSUES

aspects of biomedical engineering. Those that follow principally affect the clinical aspects. Health care systemn size. A potent force is the increasing recognition of the size of the health care "industry." In 1972 the nation spent $83.4 billion on health care; this represented 7.6 per cent of our gross national product. This year the amount is expected to exceed $100 billion. This sizeable market has attracted the interest of segments of business and industry which feel they may have a product or service to sell in the health care field. Included in this group are the high-technology industries which have experienced sharp reductions in the aerospace and military markets. They are aggressively exploring new markets, and the biomedical field seems attractive. The educational implications relate to meeting industry's needs for persons with engineering knowledge (if not experience) in health care. Hospital costs and hospital economics. These two interrelated topics have had a remarkable effect. The rapidly rising costs of medical care, and especially the costs of hospital services, have led to public pressure to contain costs. Hospital costs were the last to be released from federal wage-price controls, and proposed legislation on national health insurance contains in all versions some provision to monitor costs. These forces alone tend to put pressure on hospitals to increase efficiency and reduce costs. Since hospitals are labor-intensive, this pressure, in turn, suggests that hospitals should consider various forms of automation, labor-saving devices, and technological systems which enhance productivity or reduce costs. These forces are being augmented by changes in hospital economics. Previously most hospital revenues were not derived from payment of charges, but were obtained largely from the reimbursement of certain classes of costs by third-party payors. This cost-reimbursement program contained no incentives for cost saving and served as a deterrent to capital expenditures for devices or systems whose main benefit was reduction in operating costs. Thus, current and projected changes in reimbursement methods are motivating hospitals to consider technologic systems and devices which are cost saving or labor saving. This increasing interest in applying engineering science and technology and their products has an effect on vendors and their need for competent engineers. It also has generated a need for hospitals to have their own competent engineers to specify and operate these systems. These needs for people have clear educational implications. WHAT ARE THE RESPONSES? Review of these varied forces shows that there is no single response which is adequate. These forces require different responses. Some of the forces counteract each other or prompt conflicting or competing responses. Furthermore, the appropriate educational response depends in large measure on the particular resources of the given educational institution. Nevertheless, certain general points can be made.

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Student interest. This response is straightforward. Most educational institutions wish to respond to bonafide educational needs of students. The limitations in responsiveness stem largely from limited (or fixed) resources. Under today's constraints one educational program usually cannot expand without some contraction elsewhere pari passu. The shifting of resources from one program to another is one of the most sensitive academic administrative issues. Thus, the responsiveness of educational institutions to this force depends heavily upon the willingness and ability of academic leadership to shift resources in the face of changing requirements. Funding. What are the appropriate responses to the disappearance of federal support to graduate education in the form of tuition fees and student stipends? Certain solutions seem unlikely: The reversal of federal policy has already been discussed as an unlikely possibility. While one can consider private foundation support for the implementation of a new program, the likelihood of ongoing support of established programs or of continued support of new programs once they are established is small. Foundations gain leverage by covering the costs of implementation, not the ongoing operation of educational programs. The use of research funds to support educational efforts by the mechanism of research assistantships is traditional but is quantitatively limited. It cannot be expected to expand sufficiently to fill the need. Research funds are only slightly less restricted than training funds. and granting agencies now look with disfavor on the inclusion of additional research assistants. Universities themselves have provided funds for graduate education via tuition remissions and teaching assistantships. Again, these resources are fully obligated and cannot be allocated to new ventures without some reduction in support of the old. Two sources which remain are the student himself and his employer. The student can support himself through work-study arrangements or through guaranteed loans. Neither option is especially attractive to those accustomed to institutional support of graduate education. A number of forward-looking industries provide tuition fee reimbursement for their employees, usually only when the educational undertaking is job-related. This option is open only to those students who are employed, willing to undertake their further education on a part-time basis, and whose employer regards biomedical engineering as job-related. In summary, we are all struggling to find an adequate response to the withdrawal of federal support for graduate education in biomedical engineering, and no fully satisfactory solution is in sight, but work-study programs and industrial participation are receiving increasing emphasis. The problem is being compounded by the other forces which are all directed toward attracting more students to this educational area and forces which create need for its output product. Quantitative biology and mnedicine. These changes require an educational response. Biomedical engineering education has in the past focused primarily upon the

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IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL.

problem of providing those persons who have an engineering background with an organized and coherent program in the essential aspects of the biomedical sciences. This new force requires the converse. The fundamentals of engineering need to be taught in a fashion comprehensible to life scientists. This does not imply that it must lack rigor to be comprehensible, it is not "engineering for poets." It does, however, require extraction of the essential, relevant topics and their organization in a rational way. The examples should be drawn from areas of biology and medicine in which the engineering approach has made real contributions to scientific understanding. It is likely that this curriculum will require the inclusion of a review or remedial mathematics course. Health care system size, visibility, costs, and financing. From the prior discussion of these forces, certain consequences become apparent. Two groups of potential employers for engineers expert in the clinical field are recognizing their need for professional engineering services. Businesses and industries which are or may provide goods and services to the health care system are only now recognizing the breadth and depth of this market. The providers of health care, and particularly the hospitals, recog-

Biomedical

BIOMEDICAL ENGINEERING is generally acknowledged to have reached the point of making a major impact on life science research. The requirement of engineering participation and actual involvement from administration to carrying out of basic life science research is well documented by the millions of dollars worth of contracts and grants presently being funded through various agencies of HEW and other federal and state agencies. It appears that this beginning will continue to develop and grow. However, a vital question is whether or not this is the only useful and needed contribution of biomedical engineering to the medical health care delivery system. It appears that a major factor, perhaps the largest part of health care, has been neglected, if not totally ignored, by biomedical engineering. Only very spotty and specialized attention has been given to health care delivery itself and the biomedical industry that supports it-inManuscript received July 20, 1974; revised September 25, 1974. The author is with the Bio-Medical Engineering Center, Ohio State

University, Columbus, Ohio.

MARCH

1975

nize that engineering science and technology are important to them in their need to improve efficiency, contain costs, and provide more service. Furthermore, they now have economic incentives to invest in cost-saving, labor-saving systems and devices. The appropriate response from the educational system is to provide the variety of educational programs which is required. These range from the provision of well-qualified technicians who can operate and maintain these devices and systems to the education of high-level professionals who can devise new and innovative solutions to the vexing problems which confront the health care system today. The needs are varied and broad. The spectrum of persons required, and consequently the educational programs, is similarly broad and varied.

CONCLUSION There are many key issues facing biomedical engineering and its educational programs today. Our external environment is changing rapidly. If we are to survive, much less prosper, we must recognize these forces and develop appropriate and productive responses. Furthermore, we must do this in a thoughtful and timely fashion.

Engineering-Practice HERMAN R. WEED,

-BME-22, NO. 2,

or Research?

SENIOR MEMBER, IEEE

volving the individual or group medical practitioner, practical design to solve the actual problems of normal medical instrumentation and emergency care, the design, production and use of non-invasive instruments, and the use of systems and computer technologies to provide everyday medical care support. The problem is best appreciated by asking the question, "As a normal, average healthy American, expecting to spend one to three days in a hospital in the next five years for a fairly common ailment, but spending several hundred dollars a year for the usual private physician visits, what benefit will be received from the present biomedical engineering involvement in medicine?" With the exception of the insurance aspect of knowing that the heart pacer is there if needed or the better intensive care monitor is available in most community hospitals, the benefit will be essentially zero. In general, biomedical engineering has not been interested in the actual day-to-day delivery of normal, non-glamorous health care. Most attention has been focused on the hospital and then primarily on research aspects. Yet, the average American spends most of his health care dollars for this non-hospital type of care.

Current issues in biomedical engineering education.

107 IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, VOL. BmE-22, NO. 2, MARCH 1975 Current Issues in Biomedical Engineering RICHARD J. JOHNS, INTRODU...
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