Academic medicine : journal of the Association of American Medical Colleges
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Comparative Study
On rising medical student debt: in for a penny, in for a pound.
Using national databases of the Association of American Medical Colleges, the authors have examined reasons for the rising indebtedness of U. S. medical students, looking across the past decade at the influence of tuition and fees (tuition-fees) alone and the total costs of attending school, the effects of the changing demographics of medical school enrollments and lengthened graduation times, the relationship between the availability of school-funded scholarships and the amount of student loan disbursements, the pattern of student financial aid, and the reliance on borrowing to cover the costs of medical education. In constant dollars, the average indebtedness of students graduating from public schools increased 59.2% between 1985 and 1995, and that for graduates of private schools increased 64.2%. ⋯ In parallel, entering medical students have declared their intentions to rely more heavily on loans as a means of financing. These findings, although based on national data and trends, provide a framework for exploration of the factors affecting educational costs and financing at individual medical schools. The importance of doing so is mounting, as students may be throwing caution to the winds in the more favorable climate for borrowing, ignoring indicators of changing practice opportunities and incomes ahead.
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Historical Article
Reengineering academic medical centers: reengineering academic values?
Academic medicine is entering an era of profound, unsettling change resulting not simply from the drastic transformation of the health care marketplace but more fundamentally from the chronic, growing gap between academic medicine's seemingly insatiable demand for total resources and the supply of resources that society is willing to provide. To examine this problem, the author reviews the major factors that have shaped the development of academic medical centers (AMCs) since World War II and are now the roots of their vulnerability. The first was the major federal investment in university-based programs of science research and education that began in the 1940s; the second was the enactment in the 1960s of the Medicare/Medicaid legislation that established federal responsibility for the support of graduate medical education. ⋯ Of particular concern are the fate of the clinical investigator and the future of clinical research. The author concludes with a list of four feasible strategic options for AMCs (e.g., "build one's own system") and an extensive list of what he believes AMCs will do to respond to the stresses now upon them (e.g., capitalize on unique strengths rather than trying to compete in all areas). He concludes that it will take courage for AMCs to preserve their core values in the new era, but that this can be done if AMCs craft new adaptive structures that are better attuned to the new environment and not wedded to one that is vanishing.
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To evaluate the frequency and nature of ethical disagreements over patient care between housestaff and attending physicians. ⋯ The residents' disagreements with attending physicians over ethical aspects of patient care were common and usually concerned issues of overtreatment. Since most of the housestaff did not express their concerns, the attending physicians were largely unaware of them. The findings suggest that residency directors need to encourage housestaff to discuss their ethical conflicts with attending physicians.