Joan D Krizack.

Documentation planning for the U.S. health care system online

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graduates brings a cycle of change through fresh insights and new ap-
proaches to their respective professions.

Instructional programs for occupations in the health fields occupy a
unique place in the U.S. educational system. Whereas the controls for
most instructional programs for other occupations are determined largely
by the institutions in which they are based, the controls for instructional
programs in the health fields are almost always defined outside their
immediate institutional setting. Because most institutional programs in
the health fields interface with practical training that involves patients and
human subjects, they are more tightly controlled by legislative bodies
(both state and national) and voluntary and professional associations.
Institutions with instructional programs for occupations in the health
fields must comply with a vast and complex array of external legislation,
regulatory requirements, and professional standards of various disciplines



in the health professions and related sciences and also the biological
sciences/life sciences.

Because these outside controls change frequently and rapidly to
accommodate new developments in the health fields, they bring regular
and fast-paced change to instructional programs for health-related occu-
pations. Because instructional programs in the arts and humanities and
other related fields have fewer outside controls, they usually are not
compelled to adopt uniform requirements, revise curriculum, or reform
standards as often as instructional programs in the health fields. As a
result, the core requirements for instructional programs in these other
fields tend to vary on a national basis from institution to institution. By
contrast, the core requirements for instructional programs in the health
fields have greater uniformity throughout the country from institution to
institution. Because of the many external pressures to keep current,
instructional programs in the health fields are among the most pro-active
and highly energized programs in American higher education.

Instruction for occupations in the health fields occurs mainly in two
types of institutional setting^: educational institutions (colleges, universi-
ties, and postsecondary vocational institutions) and health care delivery
facilities. In many cases, reciprocal arrangements exist between these two
types of institution. In the instance of instructional programs that are
based at educational institutions, a significant portion of the clinical
teaching and training usually occurs in health care delivery facilities.
However, much of the teaching activities of instructional programs that
are based in health care delivery facilities are conducted at these institu-
tions. Usually, the faculty for these programs are from an affiliated educa-
tional institution. These joint programs entail considerable administrative
cooperation, both formal and informal. Because the records of these types
of program span two or more institutional settings, archivists from the
institutions involved should be prepared to collaborate in their documen-
tation planning efforts. Major sites that combine institutions of higher
education with health care delivery facilities are known as academic
medical centers or academic health centers. At these centers the functions
of health care delivery, education, and research are highly integrated. In
some instances interinstitutional archival programs have been established
at academic medical centers. For example, the archives of the Johns
Hopkins Medical Institutions encompass the university health divisions
(School of Medicine, University School of Nursing, School of Hygiene and
Public Health, Welch Medical Library) and the Johns Hopkins Hospital.

Educational degree programs and training certificate programs are the
two basic program tracks in the health fields. Degree programs are based
largely in educational institutions with practical training components in


health care delivery facilities. Training certificate programs may be based
in either educational institutions or health care delivery facilities. Certifi-
cate programs in educational institutions are usually affiliated with health
care delivery facilities, enabling students to receive practical training.

Degree programs are more comprehensive in terms of the amount of
intellectual preparation and extent of practical training than certificate
programs; they take longer for students to complete and are more costly
for institutions to run. The fee for tuition in degree programs is generally
significantly higher than in certificate programs.' However, the high
tuition costs of professional degree programs usually yield greater long-
term returns because graduates of these programs generally attain the
most autonomous and highly paid occupations in the U.S. health care
system, while graduates of certificate programs are usually limited to
subsidiary and lower-paid occupations.

Because most degree and certificate programs for occupations in the
health fields require both theoretical study and practical training, they are
most often conducted in dual settings — in educational institutions and in
health care delivery facilities. Theoretical studies are usually conducted at
educational institutions, while supervised practical training is held at
health care delivery facilities.

The practical training component is an especially critical part of
academic preparation for the health occupations. Learning how to per-
form many clinical and technical applications can only be accomplished
through the practice of doing. The experience of practical training also
affords students opportunities to apply problem-solving skills by confront-
ing the uncertainties of clinical practice in a supervised setting. Thus, in
the health fields learning by doing brings the concept of practice to the
formalism of higher education.

Instructional programs for occupations in the health fields are strin-
gently regulated and highly standardized at the program level rather than
at the institutional level. External forces from the public and private
sectors play a greater role than institutional policy in determining the
scope and standards of these programs. Professional educational and
health care associations in the private sector usually take the lead in
setting program standards and codes of professional conduct; legislative
bodies and governmental agencies, however, are primarily responsible for
adopting laws and regulations and for monitoring compliance to them.
The regulatory controls for instructional programs in the health fields
frequently contain special implications for archivists. Often they include
stipulations about the management and preservation of particular docu-
mentation. Although a central administration division such as the regis-
trar's office or academic affairs section usually administers institutional


compliance with external regulatory controls, archivists frequently bear
responsibilities for managing the long-term retention and use of this
documentation. As part of their documentation planning efforts for in-
structional programs in the health fields, archivists need to work carefully
with registrars or other appropriate administrators to identify the docu-
mentation that must be designated for long-term preservation. Documen-
tation of the credentials earned by students at these institutions is of
particular importance.

A symbiotic relationship exists between these instructional programs
and current needs in the health fields. As requirements for occupational
practice change, corresponding changes are usually also made in the
curriculum of the programs. For instance as the Clinton administration
presses for more general practitioners, medical schools are re-assessing
their curriculum with this in mind. Many of the same professional associa-
tions, governmental agencies, and legislative bodies that regulate occupa-
tional practices in the health fields also regulate the instructional pro-
grams for these occupations. These external controls function as a means
of compelling the programs to keep pace with change. The literature
published by the professional associations and governmental agencies that
regulate occupations and instructional programs in the health fields is an
especially useful information resource for archivists. As a rule, it provides
specific details about program and occupational requirements at the same
time it presents an overview of the intellectual and technical scope of the
programs and occupations.

Because instructional programs in the health fields must constantly
revise and upgrade curricula and standards, they are among the most
forward-looking and innovative programs in postsecondary education.
They are incubators for new ideas in education as well as in health care
delivery and research. Much basic research in the health, life, and biologi-
cal sciences is conducted in conjunction with instructional programs, and
the programs are often testing grounds for new policies, practices, and
materials in the health fields.


The types of educational and training institution for occupations in the
U.S. health care system are as varied as the occupations that are part of it.
The two major types of institution, educational institutions and health
care delivery facilities, can be broken down into the following categories:


Educational Institutions

• Universities

• Colleges (two-year and four-year)

• Vocational and technical schools

Health Care Delivery Facilities

• Hospitals

• Others (e.g., hospices, health maintenance organizations,
nursing homes)


Instruction for health care occupations takes place in most types of
institutions of higher education, as well as in vocational and technical
institutions. Universities generally offer a broad range of programs,
through the doctoral degree in varying configurations of professional and
research fields; most universities give high priority to research. Colleges
offer associate and baccalaureate degrees in the liberal arts or occupational
fields; many two-year colleges provide a variety of certificate programs,
and four-year colleges often conduct master's degree programs in such
fields as nursing. Vocational and technical schools offer certificate programs
and, in some cases, associate of arts degrees, leading to employment in the
ancillary health care occupations.

Educational institutions with instructional programs for the health
care professions fall into two broad groups: general educational institu-
tions with specialized programs for the health occupations, and specialized
institutions geared specifically to instruction in health care occupations.
The most comprehensive example of a general educational institution is a
university. Universities may administer any combination of professional
schools (such as schools of medicine, nursing, public health, veterinary
medicine, and dentistry), graduate and undergraduate degree programs,
and paraprofessional training programs. Colleges are also general educa-
tional institutions that have instructional programs for health care occu-
pations. Thus, archivists of many educational institutions are responsible
for the records of instructional programs for health care occupations. The
records of some publicly supported educational institutions, however, are
sometimes under the jurisdiction of public archives.

Educational and training institutions that specialize in the health care
occupations include junior colleges, professional schools, and vocational
and technical schools. The Central Maine Medical Center School of Nurs-
ing and the Forsyth School for Dental Hygienists in Massachusetts are
examples of two-year colleges that train students specifically for health


care occupations. Professional schools in chiropractic, nursing, pharmacy,
and optometry, as well as a few medical schools, exist as freestanding
professional schools or specialized institutions. Meharry Medical College
and the Philadelphia College of Osteopathic Medicine are examples of
freestanding medical schools and medical centers; the Massachusetts
College of Pharmacy and Allied Health Sciences and the Southern College
of Optometry are examples of schools for related and ancillary health
occupations; and the National Education Center, with locations around
the country, is an example of a vocational/technical school.


Although their primary function is patient care, hospitals, and to a lesser
extent other health care delivery facilities, also play an important role in
educating individuals for occupations in the health fields. Some instruc-
tional programs for nurses, physician assistants, and technicians are hospi-
tal-based. Medical internship and residency programs are usually admin-
istered by hospitals, although the physicians in charge of those programs are
members of the medical school faculty. Most programs based in institutions
of higher education, such as those for medicine, nursing, and physical
therapy, include clinical experience in a hospital, clinic, or ambulatory care
facility. The parts of the curriculum that provide clinical experience for
medical students are referred to as clinical clerkships. Hospices, nursing
homes, and health maintenance organizations also serve as sites for stu-
dents' practical experience. Although these other health care delivery facili-
ties have traditionally played a lesser role than hospitals in training health
care professionals, the trend is beginning to reverse.

Administrative relationships between educational or training institu-
tions and health care delivery facilities vary. The Council of Teaching
Hospitals identifies three levels of affiliation between hospitals and medical
schools. Graduate indicates that the hospital is used by the school for
graduate training programs only (i.e., for interns, residents, and fellows who
have completed the M.D. degree). M^/or affiliation signifies that the hospital
is an important part of the teaching program of the medical school, is a
major unit in the clinical clerkship program for medical students, and
participates in any graduate medical education program of the medical
school. Limited affiliation with a medical school indicates that the hospital is
used in the school's teaching program only to a limited extent.'^ Almost all
limited affiliations are for instructing residents and fellows only. Most
medical schools have a major affiliation with one teaching hospital and have
graduate or limited affiliation with other hospitals. Table 5-1 shows the
intersection of institutions and degree programs.




















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The institutionalization of education and training for occupations in the
health fields is a relatively recent phenomenon. For centuries, individual
apprenticeship was the primary means of preparation for these occupa-
tions. In the United States during the eighteenth and nineteenth centuries
the process of apprenticeship was gradually formalized under the aegis of
special courses and placed in institutional settings, mainly hospitals and
educational institutions. Preparation for the health occupations thus en-
tered the realm of higher education.

For most of the nineteenth century, medical, dental, pharmacy, and
veterinary schools were proprietary institutions that emphasized the prac-
tical elements of their professions. The faculty mainly included commu-
nity practitioners whose teaching activities were secondary to their prac-
tices. Teaching consisted for the most part of lectures to large numbers of
students. 5

As progressive new approaches to teaching and research in medicine
and the biological sciences evolved in Europe, many American medical
students and physicians traveled to European universities and research
institutes to study. When they returned, they brought a spirit of reform
and new ideas. Many of these European-trained physicians joined the
faculties of the leading medical schools and led the revision of curriculum
to incorporate more laboratory instruction, direct participation of students
in patient care under faculty supervision, and the teaching of new discov-
eries in bacteriology and other medical sciences. The widespread publicity
given to medical advances and discoveries in bacteriology made medical
students eager to learn about them. Popular demand for the most current
medical knowledge in conjunction with the introduction of higher educa-
tional standards gradually forced all medical schools either to adopt
curriculum reform or be faced with closure owing to declining enroll-
ments and rising expenses.^

Despite the promising beginning of nursing education with the intro-
duction of the Nightingale model, the rigor of the nursing curriculum
declined as hospitals assumed control of nursing schools. In hospital-
based schools the service needs of the hospital frequently took precedence
over formalized studies. In many instances nursing students became little
more than a source of cheap labor for the hospitals in which their schools
were based. ^

The introduction of European teaching models eventually helped to
raise the quality of medical, dental, pharmacy, and veterinary education
in the United States during the ninteenth century. The trend toward


formalizing education in these fields was further enhanced at the turn of
the century. Various legislative movements that were directed toward
establishing more rigorous standards for health care practice sprang up at
both the state and national levels. The passage of new laws and regula-
tions covering practice in health care had great impact on instructional

Hospitals, schools, colleges, and universities were compelled to im-
prove instructional programs to prepare students for licensing and certifi-
cation procedures. Institutions that produced poorly prepared graduates
who failed to obtain a license or certification for practice were eventually
affected economically by the loss of students. These institutions either had
to close or radically revise their educational and training procedures to
meet changing standards because prospective practitioners sought to
attend institutions that would best prepare them for licensing and board
certification. The tightening of licensing and certification procedures
eventually made the educational and training process much more com-

Authority over professional education gradually passed to the profes-
sional societies. For example, the Council on Medical Education of the
American Medical Association (AMA) began to accredit medical schools in
1905. Subsequently, most states began to restrict licensure to practice
medicine to graduates of AMA-accredited schools. The council gradually
raised the standards for accreditation, which contributed to the drop in the
number of medical schools from over 160 in 1900 to 86 in 1920.^

The medical department of the College of Philadelphia was the first
American medical school to be established. Founded in 1765, it was based
largely on the model of the University of Edinburgh. ^o In 1821 the first
American school of pharmacy, the Philadelphia College of Pharmacy, was
founded. ^^ Formalized, institution-based dental education also had its
beginnings in the early part of the nineteenth century. In 1825 the first
dental school in North America was established in Bainbridge, Ohio;
however, the Baltimore College of Dental Surgery, which opened in 1840,
actually was the prototype for dental education in the United States.'^ In
1855 the Boston Veterinary Institute, the first veterinary college, was
established.^^ Toward the end of the nineteenth century, in 1873, the first
school of nursing in the United States was established at Bellevue Hospital
in New York City. An independent institution modeled after Florence
Nightingale's educational specifications, the Bellevue school was organ-
ized and administered by a board that had no ties to the hospital. ^"^ Public
health did not exist as a profession until the early part of the twentieth
century. Although public health courses had been an occasional part of
the curriculum of medical, nursing, and dental schools, the first formal-


ized school of public health was established in 1916 at the Johns Hopkins
University through an appropriation from the Rockefeller Foundation.'^


Both the number and the kinds of instructional programs for occupations
in the U.S. health care system have grown significantly since 1950.
Although their increase can be attributed partly to the overall growth in
higher education, it has largely resulted from the expansion of occupa-
tions within the health sciences and health care delivery and the need to
develop corresponding educational programs. The broadening of health
care delivery throughout the population, along with the rise of research in
the health sciences, has led to a general increase in the number of
personnel working in the health fields. Transformations in research and
patient care, especially the use of the team approach, have in turn
engendered many new occupations.

One hundred years ago, patient care consisted largely of the ministra-
tions of individual practitioners of widely varying qualifications. The
primary practitioners included physicians, nurses, midwives, apothecar-
ies, and even ministers and veterinarians. In urban areas with many
well-qualified practitioners, physicians led patient care activities, while
other types of practitioner assumed secondary roles. In remote rural areas
where trained physicians were scarce, however, midwives, nurses, apoth-
ecaries, and, in some instances, veterinarians frequently assumed the role
of the primary health providers. Most of these practitioners made house
calls and maintained offices in which they treated patients.

Today, by contrast, large teams of health care professionals are involved
in treating individual patients, requiring the site of patient care to be moved
from homes and practitioners' offices to hospitals and other health care
delivery facilities. Another factor in this shift to treating patients in hospitals
has been the ascending importance of the clinical laboratory in diagnosis
and treatments. Physicians need, for example, x-rays and blood chemistry
tests to properly diagnose and treat patients. A contemporary health care
delivery team includes as many as twenty or thirty highly specialized
workers from a variety of occupations. A physician specialist usually serves
as the "captain" of the team, which consists of other physician specialists,
nurses, technicians, therapists, and so on. New, specialized occupations in
nursing, technical assistance, and ancillary care have evolved largely in
conjunction with the expansion of diagnostic and therapeutic procedures,
the enactment of new social and economic policies, and new approaches to
the distribution of responsibility in patient care. Fundamental changes in
health care practice have led to the creation of criteria and standards for


many of these new occupations. Events such as wars, civil unrest, and
national disasters have also contributed to changes in patient care. For
example, new modes of triage and emergency health services have been
developed in military interventions and rescue operations. In addition social
and economic factors, such as nursing shortages, have helped bring about

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Online LibraryJoan D KrizackDocumentation planning for the U.S. health care system → online text (page 13 of 26)