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THE EFFECTS OF STATE AND FEDERAL LAWS AND REGULATIONS ON MEDICAL SCHOOLS* PHIL R. MANNING, M.D. Associate Dean, Postgraduate Affairs Professor of Medicine University of Southern California School of Medicine Los Angeles, California

A CADEMIC medical centers have become complex institutions. They are knot only the nation's main source of physicians and a major source of research, but are also sources of patient care, particularly tertiary care. Medical schools are correctly classified as major national health resources whose strength must be preserved and increased by providing an environment to facilitate teaching and discovery. Prior to World War II, medical schools received minimal financial support and guidance from the federal government. The war reminded us how useful science is to the security of the United States. In part because of this demonstration of the usefulness of scientific disciplines, the federal government began significant direct financial assistance to medical schools, particularly to strengthen research. From 1967 through 1976 more than $6 billion were granted to medical schools for research and research training,1 support that greatly strengthened biomedical research in the United States and other countries as well. Retrospectively, there have been few complaints that the federal government placed undue constraints on medical school governance and academic freedom in connection with this aid, but granting policies influenced the character of medical schools by emphasizing their research faculty. Overall, this was a positive step, but in some cases it deemphasized teaching such important aspects of practice and patient care as the doctor-patient relation. More recent federal legislation has altered the operation of medical schools. Some legislation, such as the civil rights legislation of 1964 with amendments in 1973 intended to eliminate discrimination on the basis *Presented in a panel, The Government and the Community: Their Influences on the Ethics of Medical Education, as part of a Symposium on Ethical Concerns in Modern Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 13, 1977.

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of sex, race, and national origin-affect medical schools and medical education even though they are not intended directly to address academic problems in teaching and research.2 Increasing labor conflicts which arise from collective bargaining policies by the National Labor Relations Board3 also affect medical schools. These and other events have significantly increased the medical schools' legal and administrative problems. It should be clear that I am not discussing the efficacy or the intent of these laws; merely the effect they have had and are having on medical schools. Nor am I unmindful of the benefits that medical schools have derived through federal and state financial aid. It ill behooves one interested in the future welfare of medicine and medical schools to be ungrateful for the support given medical schools by an enlightened government. Current attitudes and legislation bring with them risks which may weaken the capacity of medical schools to serve society. I shall emphasize these risks. The Health Professions Educational Assistance Act of 1963broadened in 1965, 1968, and 1971-was designed to increase the number of people in the health professions and to provide "financial distress" grants to schools with serious financial problems. This act tangibly demonstrates that legislation with specific objectives can, in fact, readily achieve quantitative objectives.4 In 1963-1964 there were 9,000 graduates from American medical schools; in 1973-1974 there were 14,000, and in 19791980 there will presumably be some 16,000 graduates.5 In 1976 the $2.7 billion Health Professions Educational Assistance Act was enacted to decrease the geographic maldistribution of physicians, to alter distribution of physicians in specialty groups by increasing training positions in family practice, general internal medicine, and pediatrics, and to decrease dependence on foreign medical graduates. This law also provides construction grants for ambulatory primary-care-teaching facilities, financial assistance to students, and incentives to practice in shortage areas with Health Service Corps scholarships for medical students who agree to enter family practice in health-manpower-shortage areas. Another provision is for capitation funds to medical schools in direct or affiliated residency-training programs in primary care, to 35% in 1978, 40% in 1979, and 50% in 1980. The schools must also admit an "equitable number of U.S. citizens who were in foreign medical schools before enactment of the Act."6 This last requirement is currently under discussion. It is likely that amendment will change the wording and details of admitting transfer Vol. 54, No. 7, July-August 1978

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students without significantly altering the law's original intent to facilitate entry into American schools of American students enrolled in foreign medical schools (see addendum: A Possible Approach). Thus, federal legislation influences medical schools both directly and indirectly. Legislation affects medical schools indirectly by placing additional administrative, technical, or bureaucratic burdens on faculty and administrative personnel who must expend time and energy to demonstrate that they are spending government money according to the intent of the regulations as interpreted by various governmental agencies. The need to document compliance, therefore, requires much time and effort and, indeed, a new layer of university hierarchy is developing to deal with accumulating red tape. President Bok of Harvard University says, "At Harvard the cost of administering five government equal opportunity laws, the Buckley Amendment, occupational health and safety rules, environmental protection, and pension reform has been running from $7.6 to $8.3 million per year."7 Some faculty enthusiasm for teaching and research may be weakened by the changed atmosphere in the academic centers brought about by added restrictions and paper work which compete with more scholarly demands for their time. Again, President Bok states, "At Harvard, for example, compliance with Federal regulations consumed over 60,000 hours of faculty time in 1974-75 alone." 8 Although these activities may nearly inundate the medical schools with technical chores, which take time and energy away from research and teaching and sap enthusiasm for scholarship, after proper adjustments by the schools and simplification of procedures by the government, the academic integrity of the medical schools will likely remain intact even if strained. Other legislation, such as the Health Professions Educational Assistance Act of 1976, has more direct effects on the academic integrity of medical schools. This law offers incentives which affect the right of schools to choose their student bodies by requiring the advanced admission of American students enrolled in foreign schools. Currently, several of our most illustrious medical schools have rejected this federal aid and are challenging the constitutionality of the act.9 That this response can occur is encouraging, and demonstrates that a few schools will exercise freedom of choice in at least some of their academic activities rather than greedily swallow money to establish programs with which they disagree. This Bull. N.Y. Acad. Med.

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reaction may be an early sign that medical schools do, indeed, value their individuality enough to preserve the diversity of our medical schools.lO* To the federal legislation must be added state legislation, and, to demonstrate the possibilities of state involvement, I shall discuss as an example a bill (California Assembly Bill No. 4179) that passed the California legislature (assembly vote 41-25, senate vote 34-0) with little or no fanfare. This law (State of California chapter 1434/1976) requires that the Board of Medical Quality Assurance of the State of California prescribe the length and content of a course on human sexuality. Graduates from medical schools applying for a California license will have to demonstrate that they have had this course in their medical school training. This applies not only to the eight medical schools in the State of California but to all schools whose graduates want a license in the State of California.11 With respect to the undergraduate medical curriculum, the new legislation to become operative on January 1, 1978 states: The curriculum for all applicants . . shall provide for adequate instruction in . . . human sexuality. The Board shall determine the content and length of training in human sexuality and the Board shall proceed immediately upon the effective date of this section to determine what training, and the quality of staff to provide such training, is available.12

Here we have a very direct influence on the medical school curriculum because some curricular planning and potential assessment of faculty quality are assumed by a Medical Quality Assurance Board which may prohibit licenses to individuals whose medical schools do not offer the required California course. The state lawmakers passed such a law because of their perception and belief that there were physicians counselling on sex who, in fact, were not well trained to do so. I concur in this appraisal but, again, I do not discuss the intent of the law. This kind of legislation is designed to compensate for the perceived narrowness of curricular planning left to the deliberations of individual medical schools. The need for this type of law is considered by some to demonstrate that legislators believe Talleyrand's remark as quoted by Lloyd George, "War is much too serious a thing to be left to military men," and may be modernized to read, "Medical education is much too serious a thing to be left to medical school faculties." *Since the presentation of this paper, Congress all but repealed its medical school transfer law by passing a bill that will end the provision a year from now. Fourteen schools have stated they will refuse to accept the students. The new law limits transfers to 5% of existing enrollments for one year and gives medical schools the right to set their own academic standards for transfer students.10 This action, I believe, supports the premise that earlier interaction among medical school faculties and state and national legislators would be beneficial to all groups.

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In California additional bills have been introduced to require medical school programs in nutrition, child abuse, death and dying, and holistic medicine. It is disconcerting to speculate what would happen to the planning of medical school curricula were just one bill passed in each of the states every other year. In four years 100 additional courses might be imposed on the nation's medical students, a legislative activity leading to chaos. The solution might include development of a national medical curriculum and monolithic curriculum planning. Diversity would be lost. Rigidity even greater than we see today would ultimately ossify the course of study or, worse, still further politicize medical students. This California statute demonstrates that if medical schools do not make decisions which the voting majority of legislators deem proper, even on curricular matters, the state will act. The legislator who engineered the bill on human sexuality acknowledged that this type of legislation might bring slight risks to the academic integrity of medical schools, but he believed the issue of human sexuality is important enough to justify some risks. Health care is an increasingly important political issue, and many politicians will likely be elected or defeated because of their stand on health issues. There will, of course, be strong pressures on legislators to support legislation to increase control over academic institutions, and it is conceivable that the ability to deliver a speech and the ability to organize an election campaign will be the chief skills required to gain direction or even control of academic institutions. It is unlikely that society will benefit in the long run if legislators assume more direct control over medical school curricula and policies. Concern with elements of cost and superficial aspects of the delivery system would undoubtedly take precedence over excellence of care. Nonetheless, both the state and national legislators are assigned respon'sibilitly to solve massive social problems that face the nation. It is necessary for those responsible for health education to help with solutions. Legislators are in an excellent position to learn the stated and perceived needs of society, but, although these perceptions can benefit curricula, they should not dominate curriculum planning. To assess and possibly to solve health problems, legislators require objective and accurate data as free as possible from political manipulation and the influence of short-term day-to-day events. Although medical schools 'and universities have experts who know a great deal about most medical problems, it is nevertheless possible that the vantage point of Bull. N.Y. Acad. Med.

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medical school faculty members allows only a limited view of social needs too narrow to formulate sound long-range institutional objectives. Better methods to identify educational needs are required to prepare graduates to solve problems in day-to-day practice. Medical school programs on such issues as human sexuality, death and dying, and nutrition have, in fact, become more important parts of medical school curricula in recent years. With pressures from society through legislators, and acknowledging that medical school faculties have not planned curriculum changes perfectly, has the concept of academic freedom outlived its usefulness'? Should it be preserved? Is it possible to preserve it? For the purpose of discussion, the definition of academic freedom given by the late Supreme Court Justice Felix Frankfurter in 1951 is appropriate: "The four essential freedoms of a university are the right to determine for itself on academic grounds who may teach, what may be taught and how it shall be taught and who may be admitted to study. 13 Can a mechanism be designed to deliver more exact information to legislators and to broaden the perception of medical school faculties about health-related problems in society? Can increased and more orderly dialogue between medical schools and federal and state governments be useful to all groups and at the same time preserve academic freedom'? In attempting to lay the ground rules to decrease conflict and to aid understanding between medical school faculties and legislators, I do not think that the villains line up on one side and the heroes on the other. Enlightened legislators, surrounded by pressure and criticism, need every assistance to obtain the proper data and gain the proper insight upon which to base legislative action which affects medical schools and health care. They have enough to do without entering by long distance the field of academic medicine, even through governmental agencies. Laws and regulations seldom can be specific enough to apply to all schools and situations equally. Interaction among medical school faculties and state and federal lawmakers should begin early as issues develop and before bills are introduced. Organized or academic medicine have usually been in a position to react after a bill has been formulated, but earlier interaction might allow more thoughtful, less hurried consideration of the impact of proposed legislation on medical schools. Bureaucratic red tape can be simplified, and cooperation between medical professors and legislators can be nurtured to the benefit of all. Vol. 54, No. 7, July-August 1978

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A POSSIBLE APPROACH

The medical school communities and legislative bodies of our country can serve each other, although the groups in general may have difficulty getting along. It would appear that a broader, more orderly, better organized and continued dialogue-outside the scope of lobbying-between health educators, medical practitioners, and legislators is warranted. How is this to be done? It is said that countless deans and college presidents visited Washington to influence their legislators on the Health Professions Educational Assistance Act of 1976. The Association of American Medical Colleges works to coordinate the resources, ideas, and philosophy of the academic medical community with the goals of federal legislators. The Association's existing mechanism could be strengthened to become more effective by providing a channel for increased interaction. Bureaucratic impediments and time constraints on busy legislators and medical school teachers for this type of interaction is, indeed, staggering, but it is difficult to visualize a mechanism that would work better. Informal dialogue now takes place at the state level, and it should not be difficult for medical school administrators to develop more formal mechanisms for dialogue with state and federal legislators. Legislators can present the needs of society and possible solutions as they see them; medical school faculty members can assess their capabilities to provide answers and, if indicated, express different points of view on particular patient and health problems and their relation to medical schools. One might develop a more orderly mechanism for state groups to interact with each other nationally, perhaps through a strengthened Association of American Medical Colleges. The national legislators could thus benefit from interaction with their state medical schools and from studies and discussions conducted by state legislators and medical school faculties. The national applicability and significance of state discussions and studies could be assessed. The mechanisms are in place but need to be approached more actively and better coordinated by the medical school administrators who are already gasping for more time to solve problems, but early involvement in problems concerning medical schools could actually use administrative time more efficiently. In all events, the burden must be assumed if medical school resources are to address problems of health and patient care and still preserve academic freedom. In short, I suggest strengthening formal mechanisms for interaction and dialogue between

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state and federal legislators with medical school administrators and faculties. I do not suggest self-serving lobbying but approaches better to define issues and to enhance innovative and sound solutions to problems. The issues are fundamental. Who will control medical education? Will experts be crippled until they become ineffective? Will the experts become discouraged with an environment which is bogged down with red tape? Can the vision of the experts be expanded to clearer and more timely perceptions of social problems in health care? The very foundation of our medical schools is at stake. The progress of medical practice and medical science may hang in the balance. Delay in establishing more communication and interaction between legislators and medical school faculties will widen the gap of misunderstanding and make solutions more difficult. ACKNOWLEDGEMENTS

I thank the following individuals who kindly discussed various issues: David Blankenhorn, M.D.; Mrs. Judy Braslow; John Cooper, M.D.; Roger Egeberg, M.D.; William Gerber, M.D.; Mrs. Frances Howard; Mr. David Jolley, Zohrab Kaprelian, Ph.D.; Mr. Joseph Keyes; Mr Robert J. Manning; Emanuel Suter, M.D.; and Assemblyman Joseph Vasconcellos-none of whom should be considered responsible for the inadequacies of this paper or the recommendations therein.

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REFERENCES Basic Data Relating to the National 6. Ibid., p. ii. Institutes of Health 1977. Office of the 7. Bok, C.: The president's report, 1974Director, NIH, p. 35, Table 23, Feb1975. Harvard Today 18:9-16, 1976. ruary 1977. 8. Ibid. Universities and the law: Legislation, 9. Culliton, B. J.: Four medical schools regulation, litigation. Science 192:354draw the line on capitation. Science 56, 1976. 197:1066, 1977. Ibid. 10. A.M.A. Newsletter 9:2, December 12, Price, R. and Bailey, S.: Summary of 1977. Health Legislation 1959-1976 86th 11. Vasconcellos, R.: Assembly Bill Number Congress-94th Congress. Library of 4179, Sec. 3, lines 29-33, p. 4. California Congress, RA 11 U.S., 76-207 ED, pp. Legislature, 1975-1976, regular session: 3, 7, 10, 17, November 3, 1976. State of California Law, Chapter 1434, Price, R.: Health Professions Educa1976. tional Assistance Act of 1976-P.L. 12. Ibid. 94-484. Library of Congress, 77-I ED, 13. Culliton, B. J., op. cit. p. i, January 3, 1977.

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The effects of state and federal laws and regulations on medical schools.

670 THE EFFECTS OF STATE AND FEDERAL LAWS AND REGULATIONS ON MEDICAL SCHOOLS* PHIL R. MANNING, M.D. Associate Dean, Postgraduate Affairs Professor of...
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