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Profess onsttee

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Health Professionsand ervices

DEPA4TMiNT OFHEALTH, EDUCATION, AND 'WEL

Public Health Service

/ Report of the Allied Health Professions..- Education Subcommitteeof the National Advisory Health Council ,

/Educationfor the Allied

Health Professionsand Services

U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE

OFFICE OF EDUCATION

THIS DOCUMENT HAS BEEN REPRODUCED EXACTLY AS RECEIVED FROM THE

PERSON OR ORGANIZATION ORIGINATING IT. POINTS OF VIEW OR OPINIONS

STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OF EDUCATION

POSITION OR POLICY.

U.S. DEPARTMENT OF

HEALTH, EDUCATION, AND WELFARE

Public Health Service

Bureau of Health Manpower

Public Health Service Publication Number 1600United States Government Printing Office

Washington : 1967

For sale by the Superintendent of Documents, U.S. Government Printing OfficeWashington, D.C., 20402 Price 45 cents

The National Advisory Health Council

Allied Health Professions Educational Subcommittee

MR. BOISFEUILLET JONES, Chairman of SubcommitteePresidentEmily and Ernest Woodruff Foundation

DR. HARVIE BRANSCOMBChancellor EmeritusVanderbilt University

DR. ROBERT EBERTDeanHarvard School of Medicine

MRS. CHRISTY HAWKINSDirector of Nursing ServiceEdward W. Sparrow Hospital

DR. CHARLES E. ODEGAARDPresidentUniversity of Washington

Consultants to Subcommittee

DR. ROBERT KINSINGERDirectorDivision of Education and Public AffairsW. K. Kellogg Foundation

DR. ROBERT KROEPSCHExecutive DirectorWestern Interstate Commission for Higher Education

DR. ARNOLD KURLANDERDirectorSinai Hospital, Baltimore

DR. DARREL J. MASEDeanCollege of Health Related ProfessionsUniversity of Florida

MR. PETER G. MEEKExecutive DirectorNational Health Council

DR. A. NICHOLS TAYLORAssociate SecretaryCouncil on Medical EducationAmerican Medical Association

DR. JOSEPH F. VOLKERDirector of Research and Graduate StudiesUniversity of Alabama

Staff of Subcommittees

MARGARET D. WEST MICHAEL ALDERMAN, M.D.

MARION E. ALTENDERFER BEATRICE CROWTHER

RUTH R. JOHNSON MARIAN CHASE

* At the time of the preparation of this report these staff members were in the Division of PublicHealth Methods. With the reorganization of the Public Health Service, the health manpower ac-tivities of the Service have been placed in the Bureau of Health Manpower.

iii

William H. Stewart, M.D.

The Surgeon General

Public Health Service

Dear Dr. Stewart:

I am transmitting herewith the report "Education for the Allied Health

Professions and Services," prepared at your request by the Allied HealthProfessions Educational Subcommittee of the National Advisory HealthCouncil.

The group has been concerned both with the problems of meeting theneeds for health manpower, particularly for the allied health professions and

services, and the problems of the education of allied health manpower, and

the development of new kinds of workers. We have reviewed the supply and

the needs for personnel in the allied health field, the educational patterns, and

the availability of educational opportunities in various parts of the country.

The Subcommittee has found need for greater attention to the analysis of

duties and qualifications required for the delivery of health care services; the

development of career ladders to reduce the "dead end" jobs in the healthoccupations; and the improvement of methods to identify and recruit individ-

uals into the allied health occupations.

We have emphasized the importance of the development of a strengthened

educational structure for the preparation of health personnel, as an essential

to the provision of high quality care to all people. We believe that the Public

Health Service has a great opportunity at this time to assist in the develop-

ment of these programs and urge you to stimulate planning, development, and

implementation of new programs in these areas.

Sincerely yours,

44Aurd°144-Boisfeuillet JonesChairman

April 19, 1967

,,-...,,,,,---.:--.^',' ,,",

Contents

PagePreface xi

Chapter I. Summary and Recommendations 1

Chapter II. Health Manpower Supply and Needs 3Trends in Supply 3Needs for Health Manpower . 5Summary 9

Chapter III. Education and Training for theAllied Health Occupations 10

The Allied Health Occupations 10Educational Programs 13Discussion 22

Chapter IV.

Bibliography

Appendix A.

Appendix B.

Appendix C.

Appendix D.

The Output of Educational Programs 26Distribution of Educational Programs 26Distribution of Graduates 27Annual Graduates in Relation to Young People. . . 27Annual Graduates in Relation to Total Population . 34Annual Graduates in Relation to Hospital Beds. . . 34Needs for New Programs 35

36

Summary of Aid Available Under Allied HealthProfessions Personnel Training Act of 1966 40

Annotated Bibliography of State Reports onAllied Health Manpower 41

Universities wi'.h Schools of Allied HealthProfessions 46

Tables 48

vii

Tables

Tablenumber Page

1. Supply of health workers, by level of train;ng: 1966 4

2. Persons in the health occupations in relation to the labor force:1900-75 5

3. Personnel needs in hospitals: 1966 7

4. Personnel needs in extended care facilities: 1966 8

5. Distribution of selected allied health personnel in relation topopulation, by geographic division 9

6. Examples of allied health professional and technical occupa-tions for which education is provided in 4-year colleges, juniorcolleges, and technical schools, by level of education and majororientation 11

7. Educational programs in selected health occupations, bycategory of personnel and type of institution: 1965 14

8. Number of educational programs and number of jurisdictionswith programs for selected allied health occupations: 1965 . . . . 26

9. Baccalaureate graduates in relation to young people for selectedallied health professions, by geographic division: 1965 27

10. Graduates at less than baccalaureate level in relation to youngpeople of programs for selected allied health occupations, bygeographic division: 1965 28

11. Graduates of programs of education for selected health occupa-tions allied to medicine and relation to hospital beds, by geo-graphic division: 1965 34

12. Needs for selected allied health personnel in hospitals and ex-tended care facilities and annual number of graduates 35

Figures

Figurenumber

1. Employment in health occupations in relation to major occupa-tional groups: 1940.65

2. The medical services pyramid

3. Baccalaureate graduates of programs in selected allied healthprofessions in relation to young people: 1965

4. Graduates at less than baccalaureate level of programs in se-lected allied health occupations in relation to young people:1965

Page

6

13

28

29

5. Graduates of programs in selected allied health occupations inrelation to young people in each geographic division: 1965. . . . 29

6. Dental hygiene graduates in relation to young people and loca-tion of programs: 1965 30

7. Medical record librarian graduates in relation to young peopleand location cf programs: 1965 31

8. Occupational therapy graduates in relation to young people:1964 32

9. Physical therapy graduates in relation to young people: 1964 32

10. Medical technology graduates in relation to young people andlocation of programs: 1965 33

11. Radiologic technology graduates in relation to young peopleand location of programs: 1965 33

iz

Appendix Tables

Tablenumber Page

1. Number of baccalaureate programs in selected allied healthprofessions, by geographic division, State, and program: 1965 . . 48

2. Number of programs at less than baccalaureate level in selectedallied health occupations, by geographic division, State, andprogram: 1965 50

3. Number of baccalaureate graduates of programs in selectedallied health professions, by geographic division, State, andprogram: 1965 52

4. Number of graduates at less than baccalaureate level of trainingin selected allied health occupations, by geographic division,State, and program: 1965 54

5. Graduates of programs for selected allied health occupations,by geographic division, State, and program: 1., ,i 56

6. Graduates in relation to population of baccalaureate and lessthan baccalaureate level programs for selected allied healthoccupations, by geographic division and State: 1965 58

7. Number of additional annual graduates needed to bring eachState up to the level of the highest SW ., by State and level ofprogram: 1965 66

z

Ii

Preface

Surgeon General William H. Stewart, in his charge to this Subcommittee,reviewed the general picture of health manpower needs in the United Statesand the concerns of the Public Health Service in this area. He discussed thestudies and findings of the Surgeon General's Consultant Group on MedicalEducation in 1959, and the resulting Health Professions Educational Assist-ance Act in 1963, and the findings of the Surgeon General's Consultant Groupon Nursing, and the ensuing Nurse Education Act of 1964. He pointed tothe health manpower problem which should next be facedthat of the alliedhealth professions and services. He called attention to the lack of a coherenteducational structure for preparation for the health services, to lacks in facultyand curriculum, and to the need for creative thinking and experimentationand for a systematic approach to better utilization of health manpower.He discussed in general terms the legislative proposal, then before theCongress, to provide assistance to education for the allied health professionsand services.

The Surgeon General then asked the Subcommittee to help him in twoways: To prepare guidelines to help meet these manpower needs, and toprepare a document which could be of help to the health professions, toeducational institutions, to public health officials, and others, in the 'dead&cation of needs, the development of educational programs for the allied healthservices, and in suggesting new paths and new opportunities.

The group has followed the development of the legislation which has nowbeen enacted, and has consulted with the Subcommittee staff and with othersin the development of policy recommendations le "lig to the implementationof the Allied Health Professions Personnel T. -'r ng Act, P.L. 89-751.

In this document the group, in response to the Surgeon General's request,reviews the situation with respect to manpower supply and needs, educationalpatterns, and availability of educational opportunity, and makes recommenda-tions for the future.

xi

Chapter I

Summary and Recommendations

There are now major unmet needs for health man-power. Indeed, the lack of adequate health manpoweris a most serious problem as we aspire to bring thefull potential of modern medicine to all members ofv.ir society.

Needs in medicine, dentistry, and nursing havereceived major attention for a number of years, andfairly well-defined goals for educational progress andexpansion have been established. But with a fewexceptions relatively little attention has been givento the needs and the educational potential for themany allied health occupations which are essentialto modern health services.

Today no one or two individuals alone are capableof acquiring the breadth of knowledge to deliver therange of potential health services. Many types ofskills must be drawn on to provide comprehensivehealth care. The concept of the health team is anold one, but one more honored in the breach than inpractice. The problems are found both in the avail-ability of personnel, and the ways in which they areused. This unfortunate situation in part is the resultof haphazard development of educational programsfor health workers, both professional and technical,and in part to organizational patterns for the deliveryof health services, which seldom facilitate the pro-vision of personal, continuous, and comprehensivecare.

This report is concerned with the problems ofmeeting needs for health personnel, particularly for

the allied health professions and services. It is con-cerned primarily with education, while recognizingclosely woven needs with respect to improved utiliza-

tion, to the development of new kinds of workers,and to the organizational setting in which healthservices are provided. But it recognizes the need forcomprehensive planning for the development of edu-cation for health service, and for strengthened inter-relationships among these fields.

The "allied" health occupations include a broadrangeperhaps every group beyond medicine anddentistry. We speak often of professional and tech-nical fields, but the terms tend to defy definition. Aprofessional is presumably educated to develop ahigh degree of professional judgment, and insofaras possible he should use that capability at the levelof diagnosis, planning, supervising, and teaching, aswell as at a specialist level. By the same token, theprofessional person should not have his time encum-bered with repetitive tasks which require less thanhis best talents. This is true for the sake of society,which has many unmet needs which can only be filledby a highly-prepared person. But it is also true forthe sake of the professional who needs the challengeof tasks and opportunities that require his specialtalents. Thus we need not only more professionalpeople, but more and new kinds of technicians andassistants as well.

Our goal of having comprehensive health servicesavailable for all people requires an educational struc-ture of a magnitude sufficient to supply adequatenumbers of well-prepared personnel, and of an or-ganizational pattern that promotes the developmentof smooth-functioning health teams. Today we haveneither. For the allied health occupations the outputof schools is grossly inadequate. At the same time,the placement of educational programs is sadlyfragmented.

There is a great opportunity today for the PublicHealth Service to assist in the development of educa-tional capability, and to encourage the developmentand demonstration of effective and efficient use ofhealth manpower. The recent enactment of the AlliedHealth Professions Personnel Training Act is alreadygiving impetus to developments in this area.

Other recent legislation will have an impact on thetraining of health manpower. As an integral part ofcomprehensive regional medical programs, training

1

programs of continuing education for physicians andother health occupations may receive assistance underthe Heart Disease, Cancer and Stroke Amendmentsof 1965 (P.L. 89-239). Under the ComprehensiveHealth Planning and Public Health Services Amend-ments of 1966 (P.L. 89-749), planning programswill identify health manpower needs as they relateto comprehensive health services. Specific pr.:visionsauthorize the Surgeon General to make grants to anypublic or nonprofit private agency, institution, or otherorganization for training projects of two types: (1)-raining oriented toward the development of improvedo r ore effective comprehensive health planningthroughout the Nation, and (2) training designedto develop new methods or improve existing methodsof providing health services. In addition, the lawauthorizes grants to schools of public health forprovision of comprehensive professional training inthe fields of public health and in the administrationof State or local health programs.

We propose as a quantitative goal the doubling ofthe output of educational programs for professionaland technical workers for the allied health services,with particular attention to achieving a better balanceof opportunity among the geographic regions of theUnited States.

To assure the highest quality preparation, we rec-ommend that the Public Health Service, in coopera-tion with other governmental and voluntary agenciesand educational institutions, encourage and assist in:

2

1. Further experimentation with the developmentof university schools of allied health professions,

2. Further experimentation with the developmentof other interdisciplinary health personnel edu-cational centers,

3. Preparation of teachers both for professionaland technical programs, with formal courses ineducational methods and techniques,

4. Developmental work in interdisciplinary andcore curriculums, looking to the developmentof career ladders,

5. Studies of methods of delivery of health serv-ices with identification of new occupationalneeds and support of development of appro-priate curriculums,

6. Programs to help professional workers developmethods of making optimum use of technicaland auxiliary personnel,

7. Regional, State, and community-wide planningfor development of educational programs, in-cluding strengthened liaison between junior andsenior colleges and medical centers,

8. Studies of the roles of certification, licensing,and accreditation in providing adequate num-bers, utilization, and quality of health servicepersonnel, and

9. Recruitment for health careers, on an interdis-ciplinary basis, including studies in recruitmentmethods.

,

Chapter II

Health Manpower Supply and Needs

With the rising capacity of medicine to provide asatisfying array of services, the lowering of financialbarriers to service, and the growing acceptance of apublic responsibility to assure that all people haveadequate medical service, needs and demands formedical care continue to outstrip their availability.Today we find that health manpower is the criticalfactor in the provision of health services.

Many people are struggling with approaches to themeasurement of health manpower shortages. But noone figure can express the total need. And even if itwere possible to envision ideal health services staffingfor a community, a State, or a nation, the continuingdevelopment of new knowledge and techniques, newpatterns of service, and new methods of payment areconstantly changing the needs, both for numbers andvarieties of health workers.

As the opportunities of medical science are growing

and changing, so are the talents and skills of thepeople who provide health services. New knowledgecreates the need for new technologies, and with thedevelopment of new bodies of knowledge come newprofessions. In their wake arise new divisions oflabor. There are today a great many health occupa-tions. For some a baccalaureate or graduate educationis a prerequisite to entering the field. Others are ina state of transitionwith some programs leading toa baccalaureate degree and others requiring 2 or 3years of post-high school preparation. Still othersare identified at the technical levelwith 2-yearcollege programs leading usually to an associate de-gree. These in turn cannot always be differentiatedin work level of the graduates from some of the1-year programs of vocational and technical schools.There are also a number of categories of aides withshort term on-the-job or apprentice training.

Trends in Supply

Some 2.8 million persons were employed in thehealth occupations in 1966. The detail is shown intable 1, grouped insofar as possible by level of train-ing. These 2.8 million health personnel represent 3.7percent of the civilian labor force. The rise since thebeginning of this century is shown in table 2.

The rising level of education in the United Statesand the fast-developing technology in industry andagriculture are important among the factors which

make it possible to devote an increasing share ofmanpower to health services. It was less than 15years ago that service workers first outnumbered farmworkers, and that "white collar" workers outnum-bered "blue collar" workers. Fig. 1 indicates (on alogarithmic scale) that the rate of increase of workersin the health occupations has been even greater thanthat of all service occupations considered together.

3

1

i

Table 1. Supply of health workers, by le iel of training: 1966

Loyal of training and occupation Number of porsoro

Total 2,786,200

Physician, dentist, and other doctoral level 442,400

Physician (M.D. and D.0.) 297,000Dentist 95,400Other 50,000

Nurse (baccalaureate, diploma, and associate degree) 640,000

Other occupations which may have baccalaureate or post-baccalaureate preparation 422,000

Dental hygienist 1 16,000Medical record librarian 2 12,000Medical technologist: 40,000Occupational therapist 6,500Physical therapist 12,500Speech pathologist and audiologist 13,000Radiologic technologist 72,000Other 250,000

Other 1-3 year post-high school 531,800

Certified laboratory assistant 1,500Cytotechnologist 3,320Dental assistant 95,000Dental laboratory technician 27,000Inhalation therapist 5,000Practical nurse . 300,000Other 100,000

Short training 750,000

1 Some baccalaureate, primarily 2-year programs.2 Employed in hospitals.3 ASCP registered (both baccalaureate and less than baccalaureate). Hospitals report 22,000 not ASCP registered employed in 1966.4 Both baccalaureate and less than baccalaureate.

Source: Bureau of Health Manpower

Table 2. Persons in the health occupations in relation to the civilianlabor force: 1900-75

Year

Experienced civilian labor FeralPercent in

heakhoccupationsTOW

In healthoccepations 2

1900 29,030,000 345,000 1.2

1910 37,291,500 500,000 1.3

1920 42,205,700 650,000 1.5

1930 48,685,600 900,000 1.8

1940 51,742,000 1,090,000 2.1

1950 62,208,000 1,440,000 2.4

1960 69,628,000 2,040,000 3.0

1966 75,770,000 2,786,000' 3.7

1975 89,083,000 3,800,000' 4.3

1For 1900-30, data include civilian gainful workers 10 years old and over; for 1940, data include persons 14 years old and over in

the experienced civilian labor force; for 1950-75, data include persons 16 years of age and over in the civilian labor force.

'Includes those health occupations identifiable from decennial census data.

sEstimated by Bureau of Health Manpower.

Sources References (38) and (51).

Needs for Health Manpower

There is evidence of unmet needs for health serviceson every hand. This can be seen in relation to:

1) Population growth and change2) Differentials in health status in relation to in-

come level

3) Technological changes4) Studies of professional groups5) Hospital and nursing home staffing studies

6) State studies7) Variation among States

Population Growth and Change

The population of the United States stood at 195million in 1965. It will reach an estimated 224 mil-lion by 1975, and by 1980 it may reach 243 million.This is an average increase of 3.8 million people ayear. The number of people aged 65 and over isexpected to rise from the present 18 million to 21million by 1975, and to 23 million by 1980.

Differentials in Health Status inRelation to Income Level

The findings of the National Health Survey pro-vide ample evidence of the relationship between lowincome and poor health (26). Measuring the impactof illness by the number of days on which peoplemissed work, school or otherwise had to reduce theirusual activities, the National Health Survey foundthat those in families with annual incomes below$2,000 had more than twice as many days of restrictedactivity as those in families with incomes over $7,000

(64).

Technological Changes

The National Commission on Technology, Automa-tion, and Economic Progress has stated that new tech-nological developments have brought substantialneeds for more health manpower, with better prepa-ration (31). The Commission points out:

S

"The tasks that lie ahead include not only imple-mentation of the programs recently passed, but abroader effort to achieve the following goals: (1)fuller access to diagnostic and patient care facilitiesby all groups in the population; (2) broader andbolder use of the computer and other new health tech-nologies; (3) increased spread and use of health sta-tistics, information, and indexes; and (4) new pro-grams for training health manpower.

"One major barrier to achieving more adequatehealth care is that there are not enough physicians andother health care personnel. ..The gap between thetechnological potential and our ability to apply it ef-fectively is partly due to the lack of a significant im-provement in the proportion of physicians to popula-tion. We have also not developed the propermanpower training programs for the new technologies.We continued to hold on to our traditional and basictraining programs in the various health and medicalfields without analyzing the new technologies avail-able and the real possibility of training new categoriesof manpower who can perform many of the functionsnow carried out by highly skilled and scarce profes-sional personnel.

"One solution lies in restructuring our training pro-grams in accordance with current scientific and tech-nological developments. The only solution, in thelong run, is an increase in the number of trained med-ical personnel, physicians, nurses, and medical techni-cians in all categories."

Studies of Professional Groups

A number of studies have dealt with present andfuture needs for physicians, dentists, and nurses.Among these are the 1959 report of the Surgeon Gen-eral's Consultant Group on Medical Education (46),the 1961 report of the Commission on the Survey ofDentistry in the United States (14) , and the 1963report of the Surgeon General's Consultant Groupon Nursing (47). These saw needs far beyond the ca-pacity of the Nation's schools of medicine, dentistry,and nursing. Testimony presented before the HouseInterstate and Foreign Commerce Committee (52)and the Senate Labor and Public Welfare Committee,in support of the Allied Health Professions PersonnelTraining Act, showed parallel situations in medicalrecord library science, dental hygiene, medical tech-nology, occupational therapy, physical therapy, radi-ologic technology, and other allied fields.

6

Fig. 1. Employment in health occupations inrelation to major occupational groups: 1940-65

40 m

30 m

20 m

10 m

5m

1m

0000

,,oe"so..

White Collar

------ --....-----Blue Collar

Service ..._ ..... ...

ooo .0

...-.....000000000000000 ....

0000

.0..-.............-.... Farm....... .,

.... .............

.1o........'

I I

ono'......'

.,..

../

Health.. Occupations.00

i

1940 1950 1960

Hospital and Nursing Home StaffingStudies

Hospitals.Almost two-thirds of all health per-sonnel are employed by hospitals. A study of the staff-ing needs of these institutions, just completed by thePublic Health Service and American Hospital Asso-ciation, indicates that hospitals see a need for 257,000adlitional health personnel, if staffing needs for op-timum care are to be met (table 3). In total, the staffrequired to give optimum care would be 20 percenthigher than present staff levels.

The greatest needs, at the professional level, apartfrom nursing, are for radiologic technologists, dieti-tians, occupational therapists, physical therapists, med-ical records personnel, and social workers.

For technical personnel, greatest needs are seen forlaboratory assistants, inhalation therapy technicians,and surgical technicians.

These reports from hospitals, of course, repre-sent present patterns of service. The gross dispari-

. o....04., ,

Table 3. Personnel needs in hospitals: 1966

Category of personnel Present staffAdditional needed togive optimum care

Total professional and technical 1,332 100 257,200

Nursing service:Nurse-RN 361,000 79,500Licensed practical nurse 150,600 41,400Surgical technician 17,600 3,900Aide, orderly (except in psychiatric hospitals) 374,400 51,300Aide, orderly in psychiatric hospitals 117,600 18,500

Diagnostic services:Medical technologist 54,500 9,200Laboratory assistant 14,600 2,500Cytotechnologist 1,600 500

Histologic technician 3,900 700

Electrocardiograph technician 5,900 800

Therapeutic services:Occupational therapist 4,100 2,300Occupational therapy assistant 3,800 1,200Physical therapist 8,500 2,900

Physical therapy assistant 5,200 1,100

Social worker 10,700 5,100

Social work assistant 1,500 500

Recreation therapist 3,800 1,600

Inhalation therapist 5,600 2,200Speech pathologist and audiologist 1,200 500

Radiology:Radio logic technologist 24,000 3,900

X-ray assistant 6,000 900

Pharmacy:Pharmacist 9,400 1,900

Pharmacy assistant 5,600 900

Medical records:Medical record librarian 6,300 1,800

Medical record technician 10,100 1,800

Dietary:Dietitian 12,700 3,500

Food service manager 5,400 800

All other professional and technical 106,500 16,000

Source:. Estimates for 7,000 A.H.A. registered hospitals based on 5,300 returns in P.H.S.- A.H.A. survey.

ties between supply and demand in many fields pointnot only to training needs, but also to the need for thedevelopment of new patterns of manpower utiliza-tion.

Nursing homes and other extended care facilities.-A parallel study of the staffing and staffing require-ments of extended care facilities is being conductedby the Nursing Division of the Public Health Service.Preliminary analysis of a small sample of returns in-dicates that extended care facilities would need some

32,000 additional professional, technical, and auxiliary

workers to meet optimum care needs (table 4). Thisrepresents an increase of 12 percent over present pro-

fessional and technical staff.

Greatest needs reported, in addition to nursing per-sonnel, are for physical therapists, dietitians, occupa-tional therapists, and recreational therapists. Nurs-ing homes, like hospitals, put first emphasis onstrengthening professional and supervisory staffs.

7

State Studies

In the past 4 years studies of health manpowerneeds have been made in no less than 25 States. Someof these studies have been concerned with needs inone profession; some cover the whole range of healthservices. These studies have been made by medical andnursing societies, hospital associations, health careerscouncils, departments of health, commissions on edu-cation, mental health agencies, and employmeii.:. se-curity commissions. They all indicate severe shortagesof trained personnel. For example, the report of ajoint committee representing the University System ofGeorgia,the Georgia State Department of Education,and the Georgia Department of Public Healthshowed: Of 11 occupations surveyed, the need by1970 was estimated at 21,329three times the num-ber that could be educated under present conditions.Appendix B contains summaries oi! these reports.

Variation Among States

Disparities among the States in the supply of healthmanpower are very substantial. The ratio of healthpersonnel to population in the Northeast is more than50 percent higher than the South. These differencesare found with respect to all categories of health per-sonnel.

Three examples will show the differences with re-spect to allied health personnel. There are 27 regis-tered medical technologists per 100,000 persons inthe West North Central States, but only 13 per 100,-000 in the Middle Atlantic States. The distribution ofregistered occupati-nal therapists varies from 6 per100,000 in the Pacific States to 1 per 100,000 in theEast South Central States. For physical therapists therange is from 9 per 100,000 in New England to 2 inthe East South Central States (table 5).

Table 4. Personnel needs in extended care facilities: 1966

Category of personnel Present staffAdditional needed togive optimum care

Total professional and technical 275,000 31,900

Nursing service:NurseR.N. 31,000 6,000Licensed practical nurse 33,600 9,400Aide, orderly, attendant 177,400 10,700

Therapeutic services:Occupational therapist 1,600 800Occupational therapy assistant 1,300 300Physical therapist 2,000 1,200Physical therapy assistant 900 300Social worker 1,200 500Recreation therapist 2,600 900Speech pathologist and audiologist 300 400

Medical records:Medical record librarian 300 100Medical record technician 800 100

Dietary:Dietitian 4,600 900

All other professional and technical 17,400 300

Source: Estimates for all known nursing homes based on 499 returns in PHS survey.

8

A

Table 5. Distribution of selected allied health personnel in relationto population, by geographic division

Geographic division I

ASCPRegistered

medicaltechnologists

AOTARegistered

occupationaltherapists

1965

Members ofAmericanPhysicalTherapy

Assedatien11165

United States

New EnglandMiddle AtlanticSouth AtlanticEast South CentralWest South CentralEast North CentralWest North CentralMountainPacific

Rate per 100,000 persons

19.2 3.7 5.2

15.712.615.819.722.222.126.724.521.3

5.03.72.5

.91.74.34.33.76.2

9.05.14.32.33.64.84.76.38.4

Source: Computed from data in reference (57).

Summary

Needs for health services are great, demands are in-creasing, and the shortage of health manpower is acritical factor in our ability to meet health serviceneeds.

There are 2.8 million persons in health occupationstoday. This number will probably increase to 3.8 mil-lion persons by 1975. The expected increase in popu-lation, especially in the older years, will require everincreasing numbers of health personnel to provide ad-equate health services.

An indication of the magnitude of the present

shortage of health personnel can be obtained from re-cent surveys of hospitals and nursing homes. The re-turns show over 300,000 additional health workersare needed to provide optimum patient care.

Specific indications of needs are found in studiesmade in a number of States. Testimony in support ofthe Allied Health Professions Personnel Training Actof 1966 showed the existence of shortages of medi-cal record librarians, dental hygienists, medical tech-nologists, occupational therapists, physical therapists,and radiologic technologists.

9

Chapter III

Education and Training for the Allied Health Occupations

The Allied Health Occupations

The development of a systematic description of theallied health occupations presents several difficulties.

The first is that of language. What is a health pro-fession? For some purposes it can be defined as onefor which preparation is at least at the baccalaureatelevela point at which there is presumably some mas-tery of both the theoretical and technical aspects of thebody of knowledge of a professional area, and atwhich the student has gained a broad general educa-tion in the humanities and social sciences as well aspreparation in the biomedical sciences. But for somefields the professional organization and licensing lawsgive equal recognition to 2- or 3- or 4-year post-highschool preparation, so the above definition is a hardone to stick to.

For some fields the word "technologist" is used tomean a person with baccalaureate level preparation,and "technician" 1- or 2-year preparation. Theremight be a philologic basis for this, in the sense that"technologia" means "systematic treatment" or "apractical art, utilizing scientific knowledge, as medi-cine" while "technician" one "versed or skilled inthe technical details of a subject'; or "skilled in apractical way." There are exceptions to this usage,and at the present time, a lack of general agreementas to the educational qualifications and responsibilitieswhich differentiate between technologists and tech-nicians.

In similar fashion the word "therapist" may de-note a wide range of educational levels. A physicaltherapist has a baccalaureate degree; an inhalationtherapist often receives 1 year of technical prepara-tion. "Assistant" is another word which in some fieldsmeans 1 or 2 years of post-high school preparation, inothers a baccalaureate degree.

A second difficulty is that for many of the occupa-tions related to the provision of health services, theeducational patterns are undergoing substantialchange both in length and in locus of training. Great-

10

est attention has been given to changes in nursing ed-ucation, and to substantial growth of educational re-sponsibility in both senior and junior colleges butwith growing appreciation of the essential and com-plementary roles of educational and clinical facility.Parallel educational changes are found in most of theallied health fields.

While there is no single way of grouping the alliedhealth occupations to sharply differentiate educationalrequirements, there is a similar problem in identifyingwork areas. To make a beginning, however, in the fol-lowing table 6 the major health service occupations aregrouped by educational level and by the most typicalwork area.

A description of the functions of each of thesetypes of workers is beyond the scope of this report.Detailed information can be found in the Health Ca-reers Guidebook published by the Department ofLabor in 1965 (60).

N-Yil Types If Health Workers

Experimentation and development of educationalprograms for new types of health workers is essen-tial to the improvement of health care. Programs arenow being developed to train health workers to per-form a variety of duties which are supportive of andcomplementary to existing health occupations. It isimportant that some of these training programs andoccupations be oriented toward training individuals in"dead end jobs" who have had previous training orexperience but are blocked in their development.These programs should allow individuals to improvetheir career opportunities and to permit them toassume additional responsibilities.

Some of the new curriculums are focused towardtraining of individuals to be assistants to physicians,dentists, and optometrists. For some the training is

Tab

le 6

. Exa

mpl

es o

f alli

ed h

ealth

pro

fess

iona

l and

tech

nica

l occ

upat

ions

for

whi

ch e

duca

tion

is p

rovi

ded

in 4

-yea

r co

llege

s, ju

nior

colle

ges,

and

tech

nica

l sch

ools

, by

leve

l of e

duca

tion

and

maj

or o

rient

atio

n

Leve

l of e

duca

tion

Pat

ient

orie

nted

Labo

rato

ryM

atte

dA

slat

iois

trat

ioa

orie

nted

Com

mun

sity

orie

nted

Oils

er

Prim

arily

post

-bac

cala

urea

teA

udio

logi

stC

linic

al p

sych

olog

ist

Med

ical

soc

ial w

orke

rR

ehab

ilita

tion

coun

sello

rS

peec

h pa

thol

ogis

t

Pha

rmac

ist

Rad

iobi

olog

ist

Hos

pita

lad

min

istr

ator

Bio

stat

istic

ian

Pub

lic h

ealth

adm

inis

trat

orH

ealth

edu

cato

rN

utrit

ioni

stE

ngin

eerin

gsp

ecia

lties

Bio

med

ical

eng

inee

rM

edic

al e

cono

mis

tM

edic

al s

ocio

logi

st

Prim

arily

bacc

alau

reat

e(s

ome

with

pos

t-ba

ccal

aure

ate

clin

ical

trai

ning

)

Die

titia

nO

ccup

atio

nal t

hera

pist

Phy

sica

l the

rapi

st

Med

ical

tech

nolo

gist

Med

ical

rec

ord

libra

rian

San

itaria

nR

adio

logi

cal

heal

thte

c uo

logi

st

Med

ical

illu

stra

tor

Sci

ence

writ

er

Bac

cala

urea

te a

ndpr

ebac

cala

urea

teD

enta

l hyg

ieni

stN

urse

Ort

hopt

ic te

chno

logi

st

Pro

sthe

tist

Rad

iolo

gic

tech

nolo

gist

Ass

ocia

te d

egre

ean

d ot

her

preb

acca

laur

eate

Den

tal a

ssis

tant

Dis

pens

ing

optic

ian

Foo

d se

rvic

e su

perv

isor

Occ

upat

iona

l the

rapy

ass

ista

ntO

rtho

ptic

tech

nici

anP

sych

iatr

ic a

ide

Cyt

otoc

hnol

ogis

t*D

enta

l lab

orat

ory

tech

nici

anM

edic

alla

bora

tory

assi

stan

tX

-ray

ass

ista

nt

Med

ical

rec

ord

tech

nici

an

1 ye

arP

ract

ical

nur

seIn

hala

tion

ther

apis

tO

pera

ting

room

ass

ista

ntS

urgi

cal t

echn

icia

n

Cer

tifie

dla

bora

tory

assi

stan

t

Med

ical

ass

ista

ntM

edic

al o

ffice

assi

stan

tM

edic

al s

ecre

tary

Nur

sing

uni

tm

anag

emen

tas

sist

ant

*The

re is

als

o 1

bacc

alau

reat

e pr

ogra

m.

fairly short and for some it requires a college degrt,plus 1 or 2 years special education after college.

The following experimental and developing pro-grams are illustrative:

(a) The "pediatric nurse practitioner" is beingtrained to assume an expanded role in child health.In one of these programs nurses with the regularnursing bachelor of science degree receive four monthsof intensive training at a medical center, followed bytwenty months of field experience (63) which pre-pares them to furnish comprehensive well child careto children of all ages, to identify and appraise acuteand chronic conditions and refer them to other facili-ties as indicated, and to evaluate and temporarilymanage emergency situations until medical assistanceis available. Similarly trained nurses are also joiningthe offices of private pediatricians to act as the doctor'sassociate.

(b) A 2-year program for ex-medical corpsmenor others with comparable experience in the healthfield. The broad objective is to develop highly skilled,career-oriented assistants for physicians, who willassume responsibility for repetitive and technical tasksclassically performed by physicians. They will extendthe eyes, ears and arms of the doctor and allow him toserve more people. (28)

(c) Training of men as "medical emergencytechnicians" and ambulance technicians is conductedat a few universities. Since physicians no longer rideambulances, there is a need for well-trained ambu-lance attendants to direct emergency operations and torender emergency are on the scene and en route tothe hospital (22). New York State has recently en-acted legislation requiring training for ambulancetechnicians.

(d) Dentist's assistants. Experiments in the train-ing and use of dental auxiliaries with expanded func-tions have been conducted by the Divisions of DentalHealth and of Indian Health of the Public HealthService. In evaluating the work performed by theseauxiliary workers, no significant difference has beenfound in the quality of fillings placed by the dentistor by the auxiliary, in cavities first prepared by thedentist.

12

In New Zealand, dental nurses with expanded func-tions which include filling teeth, have functionedeffectively in the school dental health program, aftet2 years of training. They carry out a very clearly de-fined and limited range of dental operations on pre-school and primary school children, including teach-ing them good oral hygiene habits, under dentalsupervision (18).

(e) A program for the training of-1nental healthaides is being conducted in the New York area in ahospital affiliate of a medical school. The hospital, aspart of its mental health service unit established fourneighborhood service centers to be staffed by workersrepresentative of the local community. These workerswere specifically selected and trained by the hospitalstaff to be mental health aides. They are first preparedfor the roles of interviewer and expeditor, then trainedon-the-job to acquire more knowledge about theagencies and the resources that can be suggested to theneighborhood people to assist them in handling theirday-to-day living problems. These mental health aidescan provide and expedite service for large numbers ofdisadvantaged persons, and increase the understandingof the professionals of problems in the local com-munity (42).

(f) Obstetrician's assistant with much of thetraining of a nurse-midwife.

(g) Surgical assistants trained to assist in the op-erating room as "scrub" assistants. (34, 33) .

Directly related to the problem of developing newoccupations is that of properly utilizing trained peoplewhose training is outside the generally accepted andestablished academic patterns. Methods must be de-vised to provide these individuals with additionaltraining to permit them to meet the educational andlicensure requirements of their occupation. Every yearmore than 10,000 corpsmen and other health techni-cians are released from the armed services. These menhave been trained and have functioned effectively inmany areas, including medical, dental, optical, operat-ing room, physical therapy, radiology, and others.But there have been no mechanisms for finding thesemen, attracting them to civilian medical services, andutilizing their valuable skills.

Educt.tional Programs'

The balance among educational levels in thehealth service occupations is a remarkable one. Of the2.5 million workers in the health occupations, thegreatest numbers are prepared at the doctoral level,and at the 1. and 3-year post-high level. (Fig. 2.)

Fig. 2. The medical services pyramid

Yawnpot - laph Illuserstivoschool occupationseducation

9 un war Ple 'lido'

s

7

s

4

3

2

0

100,000annoy

Soon

1

OparootristSocial Wok'sSION/Ch ponoloon

This distribution of career opportunities shows lit-tle relation to the general education aspirationsof young people todaymost generally stated interms of completion of junior college, senior college,or ir aduate work. In 1965, over 45 percent of allpersons 18-21 years of age were enrolled in institu-tions of higher education. Fig. 2 suggests stronglythe need for changes in the educational structure forthe health occupations to bring it into the main streamof educational patterns.

Preparation for the allied health occupations isoffered in educational institutions at every level fromuniversity to vocational high school, in hospitals, lab-oratories, and independent schools.

Within the university settings are concentrated thepost-baccalaureate and baccalaureate degree programs.Almost all of the schools of medicine, dentistry, veteri-nary medicine, and pharmacy are located within uni-versities; although a few are independent schools.

1Mudi of the material on the curriculum and organizationof courses in the allied health programs is taken fron=*mains and on-site visits to schools by staff andof the Subcommitme.

Curriculums for physical therapy, occupational ther-apy, and social work are usually organized in univer-sity settings, with clinical training provided in anaffiliated teaching hospital. Preparation of medicaltechnologists is increasingly provided in a universityor college setting, but there are many small independ-ent hospital schools. The majority of the nursingprograms are in hospital schools, but the numbers inuniversities and junior colleges are increasing rapidly.Two-year radiologic technology programs are foundprimarily in hospitals but are increasingly being foundin university settings. Dental hygiene programs may beplaced within dental schools, but are also being estab-lished in junior colleges. Graduate schools prepare fora number of health-related specialties. Newly emerg-ing schools of allied health professions are experiment-ing with bringing the preparation for health serviceoccupations into a closer educational relationship, asare junior colleges, and other technical and vocationalschools.

To indicate this range, table 7 shows the numberof educational programs for selected health occupa-tions, by type of institution in which the program isoffered.

There are no neat patterns or structured guidelinesfor the organizational placement of educational pro-grams in academic settings. While a few schools haveeducational structures which recognize and encourageinter-relationships among health workers, a significantnumber of schools are now struggling with the prob-lem of moving from isolated curriculums towardcomprehensive programming, and there are manysmall independent schools preparing workers for asingle field. Programs vary considerably in the close-ness of the relationship between educational institu-tions and hospitals.

The patterns of educational placement and organi-zation for health occupations can be grouped:

1) Schools of the allied health professions2) Other organizational placements in universi-

ties with medical and dental schools3) Programs in other universities and colleges4) Technical and vocational schools

(a) Junior colleges(b) Other technical and vocational schools

5) Hospitals,

6) Military training programs7) Proprietary sdleob

13

Tab

le 7

. Edu

catio

nal p

rogr

ams

in s

elec

ted

heal

th o

ccup

atio

ns, b

yca

tego

ry o

f per

sonn

el a

nd ty

pe o

f ins

titut

ion:

196

5

Cat

egor

y.f

pers

onne

l

Typ

e of

inst

itutio

n 1

Tot

alU

nive

rsity

with

mac

s,sc

hool

Oth

erun

iver

sity

24-

year

colle

geJu

nior

colla

ge

Tec

hnic

al o

rvo

catio

nal

scho

olS

econ

dary

scho

ol

Hos

pita

lO

fla

bera

tsry

Inde

pand

ant

scho

ol

Phy

sici

an (

M.D

. and

D.0

.)...

.D

entis

tO

ptom

etris

tP

harm

acis

tV

eter

inar

ian

Med

ical

rec

ord

libra

rian

Med

ical

tech

nolo

gist

Occ

upat

iona

l the

rapi

stP

hysi

cal t

hera

pist

Spe

ech

ther

apis

tD

enta

l hyg

ieni

stR

adio

logi

c te

chno

logi

stS

ocia

l wor

ker

Nur

se-R

.N.

Cyt

otec

hnol

ogis

tIn

hala

tion

ther

apis

tD

enta

l ass

ista

ntD

enta

l lab

orat

ory

tech

nici

anLa

bora

tory

tech

nici

an,

assi

stan

tP

ract

ical

nur

seM

edic

al a

ssis

tant

Med

ical

rec

ord

tech

nici

an...

.S

urgi

cal t

echn

icia

nD

ietit

ian'

s as

sist

ant

Pod

iatr

ist

93 49 10 75 18 29

692 32 42 152 55

693

601,

170

75 25 94 11 147

1,00

243 1

4 12 4 S

78 453 39 6 11 63 21 37 43 29 44 44 63 26 1 7 2 2 1 11,

11,

11,

11,

11, 4 2 30 12 3 12

7 6 2 53 7 17 15 64 11, 11

, 3 1 11, 7 1

1=1/

11,

11,

11,

11,

11,

=M

IND

11, 2' 8

349 5 56 3 291

102 11

,

11, 3 11,

11, 9 1 11,

11,

1=1/

11,

11,

11,

IMM

O

11,

11,

11,

11,

19 11,

11,

=M

IND

15 31 123 4

47 3 10

133 28 21 2

111M

11,

11,

11,

11,

11,

11,

11,

11,

11,

11,

11,

11,

11,

11,

11,

30 5 1654

913 5

1 11,

INIM

6111

M

11,

1=1/

11,

11,

11,

11,

11,

11,

11,

11,

11,

11,

1=1/

11,

11,

11,

11,

11,

60 11,

1=1/

11,

1=1/

11,

11,

11,

11,

11,

11,

11,

11, 7

133 3

572

781 48 20 2 118

232 12 6 1 11

,

15 54$

11,

11, 1 11,

11,

11, 1 11,

11,

371 2

=M

IND 1

11 11, 11,

11,

11, 5

1 in

clud

es in

stitu

tions

in 5

0 S

tate

s, D

istr

ict o

f Col

umbi

a, a

nd P

uert

o R

ico.

20ff.

ring

eith

er d

octo

ral o

r m

aste

r's d

egre

e an

d ha

ving

a p

rogr

am in

libe

ral a

rts

with

1 o

r m

ore

prof

essi

onal

sch

ools

.3

Incl

udes

1 n

ot a

ccre

dite

d.

Sou

rce:

Com

pile

d fr

om d

ata

in a

ppen

dix

tabl

es 1

and

2.

tain

aken

inan

innu

nlai

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tiosu

r--"

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,44.

040a

ushz

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#11

Schools of the Allied Health Professions

A promising approach to education for the healthprofessions at the baccalaureate and graduate leveltoday is the grouping of a number of he:11th curricu-lums in a college or school within a university medi-cal center. In this approach the individual curriculumsgain status and strength. The programs which are in-herently related are placed in an environment whereconstant interaction is possible. With the combiningof several programs in a college or central unit, du-plications in such areas as administration, faculty, andfacilities can be minimized. More importantly, indi-viduals who will later work together in the medicalscene are prepared together. Communication withother health professionals, a critical factor in the pro-vision of health services, is learned during their edu-cational experience.

Nine universities with medical centers have or aredeveloping formal structures for interdisciplinaryprograms in preparation for the allied health pro-fessions:2

Loma Linda University Loma Linda, CaliforniaUniversity of Califor-

nia, San FranciscoMedical Center

University of FloridaIndiana UniversitySt. Louis UniversityState University of

New York at BuffaloOhio State UniversityUniversity of

Pennsylvania

San Francisco, CaliforniaGainesville, FloridaIndianapolis, IndianaSt. Louis, Missouri

Buffalo, New YorkColumbus, Ohio

Philadelphia, PennsylvaniaTemple University Philadelphia, Pennsylvania

A tenth school, Northeastern University, has a divi-sion of allied medical sciences, which while not partof a medical center, is closely affiliated with thehospitals, medical and dental schools, and clinics inthe Boston area. Other universities are actively explor-ing or studying such program development. The fol-lowing discussion is based on the programs of these10 universities.

2 Since the preparation of this report, other universitieshave or are developing schools of allied health professions.Some of these are: University of Alabama, Birmingham,Alabama; University of Illinois, Chicago, Illinois; Universityof Kentucky, Lexington, Kentucky; Boston University (Sar-gent College), Boston, Massachusetts; State University ofNew York Downstate Medical Center, Brooklyn, New York;Jefferson Medical College, Philadelphia, Pennsylvania; Medi-cal College of South Carolina, Charleston, South Carolina.

Organization.These schools with formally struc-tured curriculums in the field of allied health are pri-marily administered and budgeted in one of twoways: they are either independent schools in a medi-cal center, equal to the school of medicine or nursing,or they are administered by the school of medicine asa department within the school. The programs atLoma Linda University, University of Florida, St.Louis University, the University of Pennsylvania, theState University of New York at Buffalo, and TempleUniversity are administered as separate schools in anacademic medical center. The programs at Ohio StateUniversity and Indiana University are administered asdepartments within the school of medicine.

There is considerable variation in the organizationand grouping of health professions education in theseuniversities. In some the programs are tightly organ-ized and administered in a single organizational unit.In other universities the health programs are locatedin one or more departments and are coordinatedthrough a dean or vice president for health affairs. Instill others, some of the allied health programs arelocated in a school of allied health professions andsome in the dental school, the school of arts andsciences, or university hospital center, with little coor-dination. In each case, however, there is some univer-sity organization to provide program quality andflexibility.

An example of a tightly-knit organization is theCollege of Health Related Professions at the Univer-sity of Florida, which includes programs in medicaltechnology, physical therapy, occupational therapy, re-habilitation counseling, health and hospital adminis-tration, clinical psychology, communicative disorders,and a Rehabilitation Research Institute. An exampleof a university which has some health programs inthe School of Allied Medical Professions and in otherparts of the university is the University of Pennsyl-vania. In the School of Allied Medical Professionsbaccalaureate degrees are awarded by the divisions ofmedical technology, occupational therapy, and physi-cal therapy. In addition there are health curriculumsoffered by five other units of the university: the DentalSchool (dental hygiene program), the School of SocialWork (medical social work program), GraduateSchool of Arts and Sciences (clinical psychology andbiomedical electronic engineering), the UniversityHospital (inhalation therapy, radiologic technology,medical technology) and the Graduate Hospital (his-tologic technology, medical records science and radio-logic technology).

15

Northeastern University offers programs leading toa baccalaureate degree and organized on the coopera-tive plan of education in which students alternateperiods of academic study on campus with periods ofpaid employment in jobs related to their professionalobjectives. These programs are medical technology(College of Liberal Arts and Lincoln college),speech and hearing therapy (College of Education),physical therapy (Boston Bouve College), pharmacy(College of Pharmacy), and nursing (College ofNursing).

There are nursing programs or colleges of nursingin all of the 10 universities listed above. However,in only two of them are the schools for nursingorganizationally related to the allied health programs.St. Louis University has a combined School of Nurs-ing and Health Services. During the first 2 years thestudents in the school attend combined classes in lib-eral arts, anatomy, physiology, psychology, and med-ical ethics. At Temple University, nursing is one ofthe programs in the College of Allied Health Sciences.In other universities, the nursing program is in aseparate school or college of nursing, which may be inthe university health center. At Loma Linda Univer-sity, the students in nursing and some of the alliedhealth professions combine classwork in physiology,bacteriology, pathology, and introduction to medicine.Other course work, such as psychology, counseling,anthropology, and history is also open to other stu-dents.

Eight of the ten universities have programs in dentalhygiene. Each is administratively related to the dentalschool. Two dental hygiene programs are of particularinterest. The first, at Loma Linda University, combinesclasses in microbiology and pathology for dental hy-giene and nursing students. The second, at Northeast-ern University, has flexibility in the educational pat-tern. Students can earn either an associate of sciencedegree or a baccalaureate degree in denial hygiene.Graduates of the associate degree program may trans-fer their credits to complete the requirements for abachelor of science degree by part-time study. North-eastern University is affiliated with Forsyth School forDental Hygienists. Students take their studies at North-eastern and earn an associate degree from its UniversityCollege, at the same time they earn a certificate indental hygiene from Forsyth. Graduates of this pro-gram may also complete the requirements for a bache-lor of science degree by part-time study in the sciences.

Baccalaureate level programs. Curriculums offered

16

at the baccalaureate level in some of these 10 univer-sities are: medical technology, occupational therapy,physical therapy, medical record library science, dentalhygiene, radiologic technology, medical dietetics, andmedical illustration. In addition to 4 years of academicstudy some of the programs require clinical training inthe year following the awarding of the baccalaureatedegree. These curriculums usually include 2 years ofstudy in the liberal arts and sciences prior to specializa-tion in a health profession. During the first 2 yearsvery few courses are offered specifically for students inthe allied health professions. The ones which areoffered are generally introductory courses to the healthoccupations or basic sciences.

During the last 2 years of baccalaureate degree pro-grams, most of the schools include in the curriculumsubjects which are common to; and are required for,all students in health related occupations. The back-ground courses typically include medical terminology,medical ethics, medical records and administration,anatomy, physiology, pathology, and psychology. Someof these courses are combined for only one or two ofthe occupations. Usually the combined courses are forthose occupations in which the course content providesbackground information and supportive skills ratherthan specialized skills. Courses providing specializedtraining related only to one of the occupations aretaught in dasses specifically directed to the needs ofthat occupation.

Examples of specialized courses and classes whichhave been combined in some of the schools of alliedhealth professions are:

Pathology and microbiologyclasses combined forstudents of physical therapy, occupational therapy,medical records administration, dental hygiene, andnursing.

Physiology and anatomy--dasses combined forstudents of occupational therapy, physical therapy,medical records administration, and medical technol-ogy.

The occupational therapy and physical therapy pro-grams share the greatest number of combined courses.These may include anatomy, physiology, applied neu-roanatomy, kinesiology, psychology, child develop-ment, and a survey of the field of emotional andphysical rehabilitation.

The combined clinical experience, planned in sucha way as to insure that students are prepared to workas part of a medical team is an essential part of theprogram in schools of allied health professions. Some

schools offer courses on medical and surgical disorders,with discussions on a variety of medical problems, andparticular emphasis on the role of each of the healthrelated occupations in the diagnosis and treatment ofthe disorder. One of the schools requires, for all stu-dents enrolled in the allied health programs, attend-ance at a series of lectures and clinical presentationsby the hospital and teaching staff on dietetics, geriat-rics, obstetrics, gynecology, urology, otolaryngology,dermatology, ophthalmology, speech therapy, sightand hearing, rehabilitation counseling, and publichealth education. These lectures emphasize the coor-dinated role for each of the health professionals in-cluding the role of the rehabilitation counselor, theclinical psychologist, and the medical social worker.

Certificate programs.Certificate programs are pro-grams providing the clinical and academic backgroundwhich lead to certification by professional associations.These programs may or may not carry academic credittoward a degree. They are usually 2 years or less inlength and are located in the university hospital ormedical school but not sponsored by the school ofallied health professions. Four of the universities withschools of allied health professions offer certificateprograms. Examples are: radiologic technology (LomaLinda University, University of Pennsylvania, OhioState University, and Indiana University), cytotechnol-ogy (Ohio State University), laboratory technology(University of Pennsylvania), inhalation therapy (In-diana University), and orthoptics and nurse anesthesia(Ohio State University).

The University of Pennsylvania also offers a post-graduate certificate program in occupational therapyand physical therapy. All students in this programhave a baccalaureate degree from an accredited collegeand the required prerequisites in natural and socialsciences.

There is a unique program combining certificate andassociate degree programs in health related fields atNortheastern University. Noncredit certificate pro-grams are offered in radiologic technique (2 years),medical laboratory assisting (15 months), dental as-sisting (3-month course in cooperation with TuftsDental School), and an institute for nursing homeadministration (a series of programs of 1 week dura-tion each on various aspects of nursing home man-agement). At Northeastern University, students whocomplete the coursework for an associate degreethrough part-time or evening study (at Lincoln Col-lege) can apply their credits toward the bachelor of

science degree at the University College. Associate inscience degrees are offered in biomedical engineeringtechnology and cht.nical-biological technology.

Graduate programs.Most of the universities withschools of allied health professions offer graduatedegrees in health related occupations. Examples ofcurriculums are clinical psychology, medical socialwork, speech pathology and audiology, dietetics, andhospital administration. These programs are typicallylocated outside of the school of allied health profes-sions. In many instances the course work is conductedin more than one department and also requires aperiod of clinical training in a hospital or medicalcenter.

The graduate programs in clinical psychology,speech pathology, and.audiology are either offered inthe graduate schools of liberal arts and sciences or inthe schools of education. Bioengineering programs areeither located in or coordinated with the departmentof engineering. The medical social work programs arelocated in the schools of social work with clinical ex-perience in hospitals. The hospital administration pro-grams are usually conducted in cooperation with theschool of business administration.

Of the nine universities with schools of alliedhealth professions, only one offers graduate courses inits school of allied health. The College of HealthRelated Professions at the University of Florida offerscourses leading to a master's degree in rehabilitationcounseling, and in a joint arrangement with the Col-lege of Business Administration a master's degreein health and hospital administration. The Depart-ment of Psychology in the College of Arts andSciences has "sub-contracted" all specialized coursesand the internship and practicum in clinical psychologyto the Department of Clinical Psychology in the Col-lege of Health Related Professions. This College pro-vides specialized courses and clinical affiliation for theprograms of the Department of Speech in the Collegeof Arts and Sciences (27).

St. Louis University offers graduate programs infive health related occupations: medical social work,dietetics, clinical psychology, speech pathology, andhospital administration. All of these programs includeclinical training in a hospital or medical environment.

The University of Pennsylvania offers graduate pro-grams in three health related occupations: medicalsocial work, bioengineering, and clinical psychology.All of these programs include training in a medicalenvironment.

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Ohio State University offers graduate degrees inbioengineering, dietetics, and clinical psychology. TheState University of New York at Buffalo offers grad-uate degrees in rehabilitation counseling, medicalsocial work, clinical psychology, and speech pathology.The programs responsible for the training of healthprofessionals outside the School of Health RelatedProfessions are closely associated and integrated withthis program through a clinical council, with represen-tatives from all of the health fields sharing representa-tion on this body.

Temple University currently offers a master's degreein medical technology through its Graduate School.Additional graduate work in the areas of nursing,occupational therapi, physical therapy, and medicalrecords is planned. Indiana University offers dietetics,and has other programs in process of formation withinthe Graduate School of Education.

Discussion.The vital element in the organizationof these allied health programs is their location in anenvironment which can foster interaction and com-munication between the students and the staff inhealth related occupations.

Combining of general background courses for oneor more of the health occupations has the advantageof utilizing the faculty and facilities more effectively.In addition, such combinations allow students moretime and exposure before making a decision to con-centrate in a specific health occupation. They alsoprovide students with a better perspective of each ofthe specific health fields and the interaction of themin direct patient care. An outline of the componentsof a course in "basic health technology" appeared ina recent article by Robert E. Kinsinger (22a). Hesuggested that a course content be developed whichwould enable students to become: (1) oriented towardhealth service resources, (2) gain experience withmedical team relationships, (3) become acquaintedwith legal and ethical responsibilities relating to healthservices, (4) gain knowledge of pathophysiology andpathopsychology, (5) learn about the diagnostic andtherapeutic techniques relating to health care, and (6)develop the necessary skills in maintaining an environ-ment which is conducive to the welfare of patients,such as record keeping, principles of asepsis, steriliza-tion, disinfection, and antisepsis.

In addition to the combined curriculums and clinicalexperience, there are values in providing student facili-ties, such as lounges and dining rooms, which willfoster and continue the communication between stu-

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dents. Such informal settings facilitate interactionamong students and reinforce classroom relationships.

Each university must develop its own program withan organizational pattern which will maximize itsstrengths of faculty, facilities, and curriculum. Combi-nations of curriculum, faculty, and organization whichwill provide the most flexibility for initiating curricu-lum changes and the best clinical experience must beresponsive to varying needs and opportunities.

Other Organizational Placements inUniversities with Medical and DentalSchools

In addition to the universities with schools ofallied health professions, some 50 other universitieswith medical and dental schools offer three or moreprograms of education for the allied health profes-sions.

The fields most commonly offered, either in themedical school, the school of liberal arts, or inde-pendent schools, include medical technology, physi-cal therapy, occupational therapy, and radiologic tech-nology. Only a few of these institutions include pro-grams in medical record librarianship. The dentalhygiene and dental laboratory technician training pro-grams are administered by or affiliated with the schoolsof dentistry.

While the majority of the programs are located inthe medical school or the college of liberal arts, manyof these universities have substantial programs forhealth services in other departments and independentschools of the university. Important examples are pro-grams of speech therapy in schools of education;dietetics in departments of home economics; andschools of nursing, pharmacy, podiatry, and optome-try. These schools often train technicians in supportiveroles for their profession.

University centers with medical schools and grad-uate c:,,:!rfinents in the sciences, engineering, andpsychoke v '.re able to offer a combination of coursesleading to advanced degrees in fields directly relatedto health occupations. Some are bioengineering (col-lege of engineering and medical school physiologydepartment), biostatistics (department of mathematicsand medical school), radiobiology (department ofphysics, medical school department of radiologicalscience), and clinical psychology (psychology depart-ment and medical school psychiatry department).

Programs in Other Universities andColleges

Close to 600 other universities and colleges offerspecialization in one or more of the allied health oc-cupations at the baccalaureate and graduate level.These programs are designed to permit students tocombine curriculums for preparation in the alliedhealth professions, liberal arts, and basic sciences.Approximately 60 of the schools offer programs inthree or more of the allied health fields. The greatestnumber of programs is in medical technology (476programs). The next largest groupings are baccalaure-ate degree nursing (166 programs) and speech therapy(109 programs). Smaller numbers of programs areoffered in radiologic technology, medical record li-brary science, social work, occupational therapy, andphysical therapy. (See table 7.) Of the 476 schoolsoffering medical technology programs, 279 have noother programs in the health field, while 189 offer atleast one other health curriculum.

These programs generally follow the educationalpatterns prescribed in the minimum training essentialsestablished by the Council on Medical Education ofthe American Medical Association. The programstypically follow one of two patternsthe baccalau-reate degree program and the post-baccalaureate cer-tificate program. The baccalaureate program permitsstudents to complete 2 to 3 years of undergraduateeducation in liberal arts and sciences and then special-ize in a health field in the last 1 or 2 years. Dependingupon the course of study, the clinical experience re-quirement may be fulfilled either prior to or just fol-lowing the baccalaureate degree.

The second type of program is the post-baccalaureate certificate program. Students with bac-calaureate degrees and acceptable college prerequisitesare given advanced standing in allied health pro-grams. The academic course of study usually lasts fora year; the length of the program may vary with thebackground of the individual student. The requiredclinical training follows the didactic training.

In medical technology programs, the minimum ed-ucational requirements for a baccalaureate degree are3 years of college plus 12 months of specialized train-ing in a hospital school of medical technology. Thecolleges give students 1 year of academic credit forthe 12 months of study.

In the occupational therapy and physical therapyprograms, the usual pattern is for students to complete

a 4-year baccalaureate program, and then fulfill theirclinical training requirements. Some colleges alsooffer a shorter post-baccalaureate certificate program inoccupational therapy and physical therapy for quali-fied college graduates. The required clinical experi-ence for certification is 6 months for occupationaltherapy and 4 months for physical therapy. The mas-ter's degree programs for physical therapy are offeredat the present time only in universities with medicalschools.

Although the training for the radiologic technologyprogram is usually 24 months, a few of the programsextend over a 4-year period and lead to a bachelor ofscience degree.

Some of the colleges offer experimental or unusualeducational programs in the allied health fields. Oneschool offers a special program of 3 years of profes-sional work in occupational therapy leading to a cer-tificate in occupational therapy rather than a collegedegree. This program is designed for individuals whomight not qualify for admission to a baccalaureatedegree program. Another college permits collegegraduates with appropriate backgrounds to be admit-ted to the final hospital year of its undergraduateprograms in orthoptics and medical technology. Thesegraduates are awarded a diploma in one of thesefields.

Technical and Vocational Schools

Vocational schools have given considerable atten-tion to the health services for many years. As early as1950 vocational schools were preparing some 5,000practical nurses annually. Today these schools preparestudents for more than a dozen health occupations. Inrecent years technical and vocational programs havedeveloped into several patterns and levels. Most im-portant, with respect to education for the health occu-pations, are the technical or vocational schools whichemphasize 1-year post-high school programs, and thejunior or community colleges which emphasize 2-year programs. But the programs of the two types ofinstitutions are by no means mutually exclusive.

In the past most of these programs have been oper-ated as independent entities, with little or no interre-lationship. Yet increasingly a common core is beingidentified that makes possible the sharing of instruct-ors, classes, facilities, library, clinical resources, andother educational services, and centers for interdis-ciplinary education are being developed. These are

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proving more effective in producing the kinds andquality of workers needed for the variety of occupa-tions in the health field. Instructional equipment andfacilities are being shared. Faculty for special sub-jects such as anatomy, bacteriology, or communityhealth and resources, are serving all groups. Andfinally, these centers are providing one location andone administrative group with which health agen-cies in the community may communicate in relationto the training of students and placement of grad-uates. Further, such centers give trainees the oppor-tunity to select from a number of occupational object-ives, and they may be more readily counseled into thecareer best suited to their capabilities.

Junior colleges.The 2-year community junior col-leges are innovating and experimenting with pro-grams for health technicians. The associate degreeprograms most frequently offered are: nursing, radio-logic technology, dental hygiene, dental assistant,medical assistant, medical laboratory assistant. Other1- or 2-year programs include: medical secretary, prac-tical nurse, medical office assistant, dental laboratorytechnician, medical record technician, and occupa-tional therapy assistant.

Two examples of such programs visited by mem-bers of this study group are St. Mary's Junior Collegein Minnesota and Foothill College in California.Seven training programs for the allied health occupa-tions are offered by St. Mary's Junior College inMinneapolis. These are medical laboratory assistant,medical record technician, medical secretary, nurse-technician, occupational therapy assistant, radiologictechnologist, and food service. Several additional cur-ricula are being proposed.

All programs require a core of general educationcourses on which technical courses build ratherdirectly. Some courses cut across departmental linesand are intended for all persons engaged in work inthe health field. Laboratory hours, utilizing the clinicalfacilities of nearby hospitals and health agencies, arecentral to each of the programs. These students' clini-cal laboratory experiences, utilizing pre- and post-discussion periods, are chosen, directed, and evaluatedby instructors to exploit the individual learning possi-bilities to the utmost.

Foothill College, one of the four community col-leges serving northern Santa Clara County, in Califor-nia, offers six health science programs leading to theassociate of arts degree. These programs were estab-lished and designed with the cooperation of an advis-

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oty group from the community to meet the specificneeds of county residents. The programs included inthe curriculum are nursing, dental assisting, dentalhygiene, inhalation therapy, medical assisting, andX-ray technology. This course-work is supplementedby actual clinical experience. In the medical assistingand dental assisting programs, clinical experience isconducted in local medical clinics, and selected dentaloffices.

Vocational schools and technical institutes.Multi-disciplinary programs offering 1-year preparation forhealth service have been developed under the spon-sorship of State and local boards of education inMassachusetts and in Wisconsin. Others are beingdeveloped in many States, including Pennsylvania,West Virginia, Arizona, Florida, and South Carolina.

An outstanding example of this type of program isthat of the Springfield Technical Institute, in Spring-field, Massachusetts. This offers seven post-secondaryschool programs to train students in allied healthoccupations. The programs offered are dental assist-ant, medical assistant, medical laboratory assistant,surgical technician, physical therapy assistant, practicalnursing, and a pilot study program for inhalationtherapists. Others are planned. All are 10 months induration except for medical laboratory assistants, 12months, and practical nursing which is 15 months.The training facilities housed in the Institute includea dental clinic, laboratory, and classrooms. Otherfacilities include a five-floor building, formerly a hos-pital, which provides medical, surgical, and nursinglaboratories; classrooms; specialized teaching units;visual aids; and a medical library. Faculty in subjectfields such as anatomy, physiology, and bacteriology,may instruct in all of the programs. Clinical experienceis gained in Springfield arel. hospitals. Cooperativehospital-school externship agreements with 16 com-munity affiliating agencies make it possible for studentsto correlate theory and practice with supervised on-the-job clinical experience. The curriculum is establishedand revised through the recommendations of an advis-ory committee representing community business, in-dustry, dental and medical professions, and hospitals.Their guidance is essential in keeping the programattuned to the medical needs of the community (49) .

Educational Programs in Hospitals

The role of the hospital as a training institution hasbeen changing over the past decades. Once the pri-

mary training ground for many health occupations, itis increasingly the locus of the clinical training andexperience, as technical schools, colleges, and uni-versities play greater roles in the education of healthpersonnel. As educational demands increase, theseinstitutions have accepted broad educational respon-sibility, while the hospitals retain the vital role ofproviding the clinical setting which is essential tothe total educational process. The development ofstrong and constructive relationships between aschool and its teaching hospital is essential to a goodeducational program.

Hospital training activities related to the alliedhealth occupations can be categorized in three areas:they provide basic education for students enrolled intheir own programs, they provide clinical experiencefor students of health related occupations in affiliatededucational institutions, and they provide inservicetraining for their own staff and for new employees.

Hospitals provide basic education for many healthrelated occupations, and clinical experience for manymore. There are 781 hospital programs for nurses and572 for radiologic technologists. Others include prac-tical nurses (232), medical technologists (133), lab-oratory technologists (118), inhalation therapists(20), cytotechnologists (48), and less than 20 pro-grams each for medical record technicians, surgicaltechnicians, medical record librarians, and dietitians'assistants.

The radiologic technology curriculum is representa-tive of post-secondary school programs of 2 years orless which are taught entirely within the hospital?Both didactic aad clinical training are under thedirect supervision and responsibility of the hospitalstaff. Examples of other programs in this group arethose for cytotechnologists, inhalation therapists, andmedical record technicians. The Council on MedicalEducation of the American Medical Association hasprepared essentials of acceptable schools for each ofthese occupations.

The clinical portion of most baccalaureate, associatedegree, and other technical programs is provided in ahospital setting, in affiliation with the educational in-stitution. Usually this follows a prescribed academicprogram in the educational institution, with clinicalexperience supervised in part by faculty from theaffiliated school. This relationship has been discussedearlier.

2 Preparation for this field is also offered as a baccalaureateprogram.

A few of the major cities have established pilotprograms in which the Board of Education and thehospitals have established a joint program for theshort-term training of allied health workers. In oneof these programs, the public school system and thehospitals have cooperated to develop a variety ofshort-term intensive technical training courses inhealth care specialties (17). The adult educationprogram includes courses for practical nurses, foodservice supervisors, operating room technicians, nurs-ing aides, orderlies, and laboratory aides. Courses arebeing planned for physical therapy aides, occupationaltherapy aides, inhalation therapy aides, and socialservice aides. In addition they are exploring the possi-bilities for courses for ward clerks, housekeepingsupervisors, pharmacy aides, central supply aides, elec-trocardiographic technicians, medical assistants, med-ical secretaries, and others. This particular communityis now planning for a unified training center forhealth occupations under the auspices of the publicschools and the hospitals. It would combine allcourses in the same building, unify the administration,and make maximum use of the classrooms, labora-tories, and instructors. Such a program can removethe cost of training from the hospital and assure qual-ity education (44) .

Hospitals have exte