North Carolina AHEC Program
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National AHEC Conference to Return to North Carolina After 38 Years
Thirty-eight years ago, North Carolina hosted the third national conference of the newly formed Area Health Education Centers program. On April 25-27, 1975, at the Grove Park Inn in Asheville, participants from across the country gathered to talk about the “decentralization and regionalization of health professional education and training.”
On July 7-11, 2014, North Carolina will once again welcome the National AHEC Conference, this time in Charlotte. More than 400 participants are expected from the national AHEC network of 55 medical schools, two nursing schools and over 240 community-based centers in 46 states. All will gather in the Queen City under the theme of “Driving Access to Quality Healthcare through Innovation, Implementation & Impact.” Charlotte AHEC is hosting the conference, and the national conference planning committee is being co-chaired by NC AHEC Program Associate Director Jacqueline R. Wynn, MPH.
Many of the founders of the AHEC concept were present at the 1975 meeting in Asheville, including the first two NC AHEC Program directors Glenn Wilson and Eugene Mayer, MD.
In celebration of the national conference’s return to North Carolina, the welcoming remarks from the 1975 conference are reprinted below:
Dr. Henry S.M. Uhl
Mountain AHEC (N.C.)
"As a transplanted Yankee who is now a native Ashevillian, I am very pleased to have the opportunity to welcome all of you to this conference. Before I leave the podium, however, I wish to say a few words. Successful innovation has seldom been a hallmark of the American educational system. One of the few permanent and fundamental changes was that which radically altered medical education as the result of the impact of the Flexner Report of 1910. Sixty years later, the Carnegie Commission report is beginning to have a major impact because change is needed again. None of us would be here today had it not been for the Commission’s report.
Let me remind you, as I keep reminding myself, that innovation in education requires a long term outlook and a good deal of fortitude and persistence. Since this conference will often concern itself informally and formally with innovation, I would like to include a brief but pertinent quotation or two. The first political scientist to merge in Western European society, Machiavelli, wrote in The Prince, 'There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things, because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new.' Nevertheless, we must try to bring about change in a rational and viable process. For it was Sir George Godfer who said, in his 1969 Michael M. David lecture at the University of Chicago, 'Individuals will only get what they need in this complicated world of medical science if competent, understanding men have organized the deployment of mutually supporting services to that end.'
It gives me great pleasure, then, on behalf of my colleagues and partners in the Mountain Area Health Education Center of western North Carolina, our board of directors, and our administrative and professional staff, to welcome you to Asheville where you will find a peaceful setting to continue our joint nationwide effort to achieve permanent change for the benefit of all the Nation. Before he died, one of the greatest humanitarian physicians who ever lived, Albert Schweitzer, was asked by some intrepid person if he would care to comment on the future of mankind. And he replied, 'My knowledge is pessimistic; but my faith is optimistic.' May all of us find the strength and the will to persist in our work with that same optimism and faith."
Photo above (from 1975): Dr. Fordham introduces President Friday and Dr. Gordon at the opening session of the conference
Dr. Christopher C. Fordham, III
University of North Carolina School of Medicine
"In this opening session we have two very distinguished speakers, and therefore I am going to limit my remarks. I would like to characterize the Area Health Education Center program as a noble experiment. It is an experiment in several specific ways: first, in testing the capacity of the State to meet many of its own crucial health manpower needs with the strong support of Federal agencies; second, in developing the potential for a productive relationship between the university and the community; third, in the consideration of the advantages and disadvantages of decentralized and regionalized health education and training; fourth, in determining whether the educational process can serve as one method for improving the distribution of health workers and access to quality health services; fifth, in measuring institutional resiliency in several kinds of institutions; and finally, in considering our capacity to comprehend and tolerate the ambiguities associated with new and complex relationships. It is a noble experiment which I believe simply must work. I would like to acknowledge and thank my own colleagues in Chapel Hill and across the State of North Carolina for their accomplishments and progress toward demonstrating the validity of this experiment."
Mr. William C. Friday
University of North Carolina
"I want to join with Dr. Uhl, Dr. Fordham, and all of our colleagues in this State in greeting all of our out-of-State friends to this session. It is a pleasure to be associated with the people of our Area Health Education program in North Carolina.
You can read a lot and hear a lot about the tensions in universities between health affairs programs and the overall university around the land. This has sometimes been exaggerated in places. I want to say that, for this State and this university, there could not e a more cooperative, forward-looking, and productive association. I think the AHEC program is an eloquent testimony to this relationship. We began this statewide program with full confidence because we knew that our colleagues would succeed. I think the evidence abounds that it has. As Dr. Fordham suggested, the Area Health Education Center program in North Carolina is really our bright new adventure in this State. In the 14 sessions of the General Assembly that I have known I have never seen anything like the legislative acceptance of this endeavor. Indeed, at this time, which we call the recession, this is the one proposal that I feel is going to continue to move forward with the level of funding that has been requested, simply because the leadership of the particular areas of North Carolina where Area Health Education Centers are now functioning has been involved and has participated well beyond the initial talk stage. AHEC is now a clearly identified public service. Legislatures put money in programs where they see competence in people, results, and services to people.
Those of you from out of State might be interested to know that in 1974-1975 the General Assembly put $28.5 million into this program in North Carolina. About $23.5 million is for the construction of educational facilities at each of our nine AHECs with the remainder being our operating budget. The General Assembly is in session in Raleigh now, and we are asking for an $8 million operating budget for the first year of the next biennium and over $11.5 million for the second year of the biennium. In other words, a major and substantial commitment, because our legislators have experienced their association with the leadership of the program in North Carolina and are confident in it.
The Carnegie Commission concluded its work after 6 years of intensive study of many problems in American higher education. This group met 33 times in 26 cities in 22 states and the District of Columbia and in Puerto Rico. I was not a good attender, for many reasons, and I felt deprived in that experience. However, the other members of the Commission did attend almost all the sessions over this span of time. This was important, because they were identified with the interested citizens, educational leadership, and political leadership all over America. One of the first major areas to which the Commission addressed itself was health manpower. I would sat that probably among all its work, these recommendations have been the most widely accepted. Area Health Education Centers grew out of that particular report. We felt that the manpower problem was then and still is one of America’s great and pressing needs.
Now, one of the people who took responsibility to guide this Commission, gave it direction, kept us together, and indeed more or less shepherded the whole group for a long, long time, was Dr. Margaret Gordon. She has had a very distinguished career in industrial relations, labor and manpower problems, has worked in the field of poverty and welfare, and is the person who I feel contributed so much to six of the major Carnegie Commission studies that we did. Margaret Gordon is especially well qualified to speak on the Carnegie Commission’s perspectives of health professions education."
Dr. Margaret Gordon
Carnegie Council on Policy Studies in Higher Education
"One of the most exciting things that has ever happened to me has been to see something that was just an idea, just a gleam in the eye, come into being and spread all over the country. I am going to talk about the genesis of the Area Health Education Center concept, but before doing that, I think it is very important to place that concept in its proper perspective in relation to the other recommendations that the Carnegie Commission made in its 1970 report, Higher Education and the Nation’s Health. All the recommendations in that report were interrelated because they addressed a common set of problems: the shortage and the geographical maldistribution of health manpower. The Carnegie Commission report started out with certain basic assumptions: that we had an inadequate system of health care in the United States; that we had a very inadequate system of financing health care; that we had a shortage of health manpower of all types, including physicians; that we had a serious problem of geographical maldistribution of health manpower; and that in all probability a full solution of all these problems would require the establishment of a national health insurance system.
The Commission had very little to say about a national health insurance system beyond criticizing and discussing the weaknesses of the existing private health insurance system in the United States, because it was a commission whose terms of reference related to higher education and it felt it would be stepping out of those terms of reference if it got into the broad and complicated problem of financing medical care.
There have been some, including a good economist friend of mine, Victor Fuchs, who have disputed the fact that there is a shortage of physicians in the United States at the time of the Carnegie Commission Report and later. We were convinced that there was. We cited a number of pieces of evidence to suggest that there was a severe shortage: long waiting lines in emergency clinics, the long working hours of the average physician (60 hours a week according to one survey), and the influx of foreign medical graduates which, as I am sure you all know, has by no means abated since 1970 when the Commission’s report was published. Consequently, a very substantial part of our report was concerned with recommendations aimed at increasing the supply of physicians. First, we wanted to see the size of entering classes to medical schools increase. Second, we wanted to see medical education accelerated, chiefly through overcoming a certain amount of overlapping between premedical and medical education. Third, we wanted to see earlier clinical experience, which medical students lacked. Fourth, we wanted to increase the supply of Physicians’ Assistants, through programs which were just barely beginning, like the one under Dr. Estes of the Duke University School of Medicine, because we felt very strongly that increasing the supply of Physicians’ Assistants and other types of allied health manpower would not only make for more effective health care assistance, but also result in utilizing the highly trained and educated skills of physicians more effectively. Finally, the report called for very substantial Federal aid to medical and dental education. I am not going to discuss these recommendations, because it would take me too far astray from the main theme of this talk, but we were very pleased that the Comprehensive Health Manpower Act of 1971 did incorporate most of the recommendations of the Carnegie Commission.
Now I am going to come to the heart of the question: how did the concept of Area Health Education Centers develop? I think we have to look at this development as being intimately bound up with the debate over how many new medical schools the Commission ought to recommend. We began with a general principle, which was backed up by some research but was in part judgmental, that there ought to be a medical school in every metropolitan area with 350,000 or more population. We identified 25 such areas in the United States that lacked an existing medical school. We held a series of meetings with experts in medical education, first in New York in December 1969 and then in Boston in February 1970 at the Harvard Medical School under the auspices of Dean Robert Ebert. At these meetings the number of new medical schools became a subject of very substantial debate. I recall particularly John Dunlop, who is now Secretary of Labor, emphatically rejecting the recommendation of 25 new medical schools. He felt that the expansion of medical education could be accomplished much more economically by simply expanding the capacity of existing medical schools.
Clark Kerr and I both thought John Dunlop’s point was well taken, although we also felt that there was a case for an adequate geographical distribution of medical schools. Medical schools do, after all, play a role in attracting health manpower to a community. They also generally improve the quality of medical care in the communities in which they are located. Sometimes this happens not because of conscientious planning on the part of medical schools, but simply because their very existence attracts physicians to the area. I am not off the subject now, because there is a very important relationship between the way in which we conceived the role of Area Health Education Centers, and the way in which we conceived an expanded role for medical schools, which we preferred an expanded role for medical schools, which we preferred to call 'university health science centers,' and indeed some of them were moving in that direction and were becoming the center for a group of health manpower educational institutions.
We felt that the function of university health science centers should be expanded, that the Flexner model was too narrow; admirable but too heavily concentrated on scientific research. We thought that university health science centers should be responsible for coordinating the education of health manpower of all types in their area; that they should cooperate with community agencies in improving health care delivery; that they should cooperate with comprehensive colleges, community colleges, and other institutions including high schools in planning and evaluating the training of allied health personnel; and that they should place a great deal of emphasis on conducting continuing education programs for physicians and other health manpower.
Considering the expanded role for university health science centers, we took another look at our recommendations on new medical schools. I decided that some of the metropolitan areas for which we had recommended medical schools were located pretty near to others. The most extreme example was Fort Worth, Texas, which was very near Dallas, so I crossed Fort Worth off the list. Finally, we came down to a list of exactly nine new medical schools.
While this discussion of how many new medical schools to recommend was going on, Dr. Mark Blumberg, who was one of several medical experts who were serving as a consultant on this work of the Commission, called our attention to some existing centers which had some of the features that we eventually identified as functions of Area Health Education Centers. One was the Mary Imogene Bassett Hospital in Cooperstown, New York. Clark Kerr had the imagination to seize on that concept as something that we might build into a major recommendation in our report. I think he deserves the major credit for taking something that he had picked up in a casual conversation and saying, now here is something that we really ought to look at seriously and consider as perhaps an important element of our report.
In the end, I sat down at my desk and spelled out the functions of Area Health Education Centers as precisely as I could, and it was really very gratifying to have the Department of Health, Education, and Welfare issue directives not so very much later which spelled out the functions exactly as the Carnegie Commission report had identified them. We saw as advantages of Area Health Education Centers some features that are very close to what I have been talking about for university health science centers. First, they would attract health manpower to the area. We actually did not have much to go on except for some anecdotal evidence and some research that suggested that residents – something like two-thirds of them – tended to settle down in practice in the same area in which they had experienced their residency training.
After our report had come out I remember meeting Dean Richardson of the Emory University School of Medicine. He told me about a town in Georgia which had had a terrible time attracting physicians. Some people in town came to him and said, 'Can you do anything to help us?' They started a residency program in the hospital in that town and it was not long before the town was beginning to attract physicians. Thus far we have had unfortunately, I think, no good statistical evidence – sooner or later we will – on the impact of Area Health Education Centers on the attraction of health manpower.
The second point is that they would improve the quality of medical care. I think this is a very clear and indisputable point. Third, they would be more effective centers for the education of family physicians for the delivery of primary care and long-term care and health maintenance than would the highly specialized university health science centers. That is a point that was spelled out more effectively, I think, in a paper given by Dr. Edmund Pellegrino at the 1972 annual meeting of the A.A.M.C., although I think it was implicit in the Carnegie Commission report.
Fourth, AHEC’s could be developed at very substantially less cost than new medical schools and yet serve many of the functions of medical schools. Fifth, they could hopefully forestall the development of medical schools in many communities that do not really need them. In fact, about the time that our report came out, I was told by Dr. Ruhe, the director of the Council of Medical Education of the A.M.A., that there were more than 70 communities in the United States, as contrasted with then nine that we finally recommended, that were attempting to develop plans for new medical school. The Chamber of Commerce gets going, the Medical Society gets going, everybody sees it as something that will contribute to the economic welfare of the community, and so we have a new plan for a medical school.
I would now like to discuss something that has recently been attacked: our identification of the locations of 126 Area Health Education Centers in the United States. This, I think, was an example of Clark Kerr’s desire, and in general the desire of the Commission, to be fairly specific in its recommendations on the ground that if you just issued a series of platitudes nobody was going to pay much attention; if you came up with specific recommendations, they might be subject to attack but they would get a lot more attention. A recent article, which many of you may have seen, by Miike and Ross in the Journal of Medical Education for March 1975, quoted another writer who said that the Carnegie Commission was exercising “unbelievable presumption” in identifying 126 locations for Area Health Education Centers in the United States. I anticipated that kind of criticism. I would like to reread a paragraph from the Report which I think is relevant:
The Commission believes that the final selection of locations for the Area Health Education Centers should be based on careful regional planning. We are therefore suggesting the location indicated by our analysis but are not firmly recommending them. However, we believe that the number of centers indicated by our analysis is probably quite close to the number that would be needed to provide adequate geographical distribution of these centers.
That plan for 126 locations was my work, by and large, but other people also had a finger in it. I remember that one day I was in Clark Kerr’s office and he was looking over the locations that I suggested and he said, 'What about Camden, New Jersey?' And I said, 'Well, Camden is part of the Philadelphia metropolitan area.' 'Well,' said Clark, who had grown up in Eastern Pennsylvania, 'people in Camden never get along with people in Philadelphia. I think you’d better suggest one for Camden.' And we did.
On another occasion, former Governor William Scranton of Pennsylvania was looking over the suggestions for locations that were in a draft that went to a Commission meeting. He said, 'I think you’ve got one too many in Western New York State. I’d take one of those out.' And he said, 'What’s the case for three in Wyoming, with its sparse population?' So the number in Wyoming came down from three to two. I am telling these stories just to point out that the Commission members did take an active role in commenting on many of the things that came out of the staff. Although the set of suggestions for 126 centers was probably not perfect, I do know that many of the communities we identified are communities in which Area Health Education Centers have since been established.
Now I am going to make some final comments of a more general nature which I hope may stir up perhaps a little discussion and debate. The problem of geographical maldistribution of health manpower in the United States, so far as I can determine, is still serious. There is a big lag in the appearance of the statistics, so we do not know exactly what the picture is today, but the latest figures I have seen, which I think are for the year 1972, suggest that between the time we were doing our analysis (we had figures fro 1968) and 1972, the ratios of physicians and other health manpower to population rose throughout the country. However, the differences from region to region did not diminish to any extent. That is, if you took the ratio of the number of physicians per population in Mississippi, which is the extreme example of an underserved state, to that in New York, you would still find that the ratio was as small in 1968, approximately. We obviously still have a geographical maldistribution problem and we are going to have to work at it indefinitely.
Area Health Education Centers will make a very substantial contribution, but by themselves will not solve the problem. I think we must move toward national health insurance combined with something like prepaid medical care programs – or health maintenance organizations, as they were called at one point by the Administration – including in those plans some provision for a premium payment for health manpower who agree to work in underserved areas. The British have a feature of that kind in the British National Health Service. I would suggest that there has to be a carrot in the form of economic benefit to attract health manpower to seriously underserved areas, which ten to be low per capita income and rural areas. I am dubious about the features of research bills that have been considered in Congress in which medical schools would be forced to extract pledges from all, or a certain proportion of, their students to go to underserved areas to practice in order for the schools to receive capitation payments from the Federal Government. I do not think that would work, and I do not see how medical schools could enforce it.
I think there are other approaches to this problem. I would like to see continued development and expansion of the National Health Service Corps, which is specifically designed to serve disadvantaged areas. And hopefully – and I think this had become increasingly true in the last six or seven years – the medical students we have today tend to be a somewhat different breed from the more traditional medical student. They seem to be more concerned about serving the disadvantaged and may be more willing to go to areas that are underserved.
I would like to emphasize the point very strongly that we recommended in our Report that Area Health Education Centers should be affiliated with a medical school and that their educational programs should be supervised by a medical school faculty. That, as some of you I am sure know, has been a subject of very substantial debate and controversy, particularly in connection with the centers sponsored by the regional medical programs. But I do not see any sound basis for disputing the fact that a high-quality Area Health Education Center program should be supervised by medical schools.
I think we are in danger of developing too many medical schools. You may have seen copies of a report that Clark Kerr made to the Southern Governors’ Conference last fall in which he was quoted rather extensively as saying that we were developing too many medical schools and that this could lead to a surplus of physicians in the 1980s. I am not much disturbed about the possibility of a surplus of physicians in the very near future, but I do think that we have a problem in the connection with the location of new medical schools. This is admirable, in a way, and the Veterans Administration has of course cooperated in the establishment of a good many Area Health Education Centers. However, it is very poor administratively to have two different agencies of the Federal Government involved in decisions as important as decisions to establish new medical schools.
Finally, there has been a lot of discussion in the last few years suggesting that we are overcoming the shortage of physicians and other health manpower. I do not think that we have overcome the shortage of physicians. I think that we have overcome the shortage of nurses in some urban areas but not in small communities and rural areas, and we certainly have not as yet overcome shortages of allied health manpower. I am not worried about the prospect of a surplus of physicians. If anybody wants to ask me why, we will leave that for a question period."