Charting the winds of change: evaluating innovative medical curricula.

The increased interest, in North America and around the world, in problem-based and community-oriented medical curricula has sparked interest in the evaluation of these innovative programs. In January 1989, the Josiah Macy Jr. Foundation sponsored a conference to consider designs for evaluation studies and the potential distinctive outcomes of the innovative curricula that might be foci of these studies. After defining an "innovative curriculum," the participants identified seven characteristics of "important evaluation studies," particularly endorsing studies that compare curricula as whole entities. The participants then identified 26 areas where differences between graduates of innovative and traditional curricula might be expected, and five equally important areas where differences are not expected. Distinctive outcomes of innovative curricula were anticipated in areas such as interpersonal skills, continuing learning, and professional satisfaction. Overall, these recommendations are offered to stimulate creative evaluations of the growing number of innovative programs in medical education.

An evaluation of subsidized rural primary care programs: IV. Impact of the rural hospital on clinic self-sufficiency.

Subsidized rural clinics and providers have long depended on the rural hospital for the care of some of their patients; the hospital has also been a source of revenue for these providers and programs. We studied a representative national sample of 116 subsidized rural clinics, focusing on the impact on rural clinic costs and revenues of the use of the hospital by the clinics' providers. Both clinic costs and revenue are reduced by the use of the hospital by rural practice providers, but costs are lowered to a greater extent than revenues, thereby enhancing the financial self-sufficiency of the subsidized clinic. The cost savings affect all aspects of clinic operation, but especially laboratory costs, community services costs, and administrative costs. The dependence of these rural clinics on the hospital indicates that the condition of subsidized rural clinics would be worsened by decreased availability of hospital services.

An evaluation of subsidized rural primary care programs: III. Stress and survival, 1981-82.

Surveys of a national sample of 193 subsidized rural primary care programs were conducted in 1981 and 1982 to determine what adaptations the programs might anticipate making given a reduction in their subsidy and what actual changes they made after the implementation of new federal policies and in the face of severe economic recession. During the period between the two surveys, nine of the 193 programs closed. The remaining programs changed elements of their operation, finances, and staffing, but these changes do not, in all cases, appear to be a direct response to subsidy reductions or increases. The programs exhibited adaptiveness and strength in the face of a potentially hostile environment.

An evaluation of subsidized rural primary care programs: I. A typology of practice organizations.

The design of a comprehensive evaluation of subsidized rural primary care programs on a large national scale is described, Its major purpose is to derive data whose analysis will answer major policy questions about the factors influencing the outcome of the major types of such programs in different communities. This first paper also delineates a typology which was developed of five principal organizational forms of these programs. This classification appears to provide suitable operational definitions of forms of rural practice as a basis for evaluating the differential impact of alternative types of primary care programs.

The modern crisis in health services--professional concerns and the public interest.

The modern crisis in the health service systems of developed nations is described. Six major issues are discussed. 1) The need for recognition of the wholeness of man and the implications of this for implementing the concept of essential unity in the development and organization of health services; 2) the creation of ample opportunity for health manpower to work effectively in team situations; 3) the need for community-wide epidemiologic intelligence that will allow for better identification of problems and solutions; 4) the need to move away from the entrepreneurial framework of health care and regionalize facilities; 5) the assessment of costs both in terms of actions and inactions; and 6) the need for the professionals and public to work together in order to improve health services.