The general purpose of this report is to collect, interpret, and integrate research findings to develop a foundation of information pertinent to nutritional-environment interaction. Then species-specific discussions of current concepts of nutritional management during environmental stress are presented. Although attempts have been made to unify terminology, contributions of different authors have not been molded to any particular scheme. It is hoped this approach will be valuable in gaining a thorough understanding of adjusting nutrient requirements to deal with existing environments and will therefore aid in developing rational managerial decisions.

Contents

• COMMITTEE ON IMPLEMENTING A NATIONAL GRADUATE MEDICAL EDUCATION TRUST FUND
• Committee Chair's Statement
• Preface
• Overview of Graduate Medical Education and the Distribution of a Trust Fund
• Principles
  • General Considerations
• Recommendations for Distribution of GME Funds
  • General
  • DME
  • IME
• Discussion
  • A Trust Fund
  • Principles and GME
  • Payment to DME Institutions
  • A Standard Payment
  • Dissociation of Payment from Individual Caseload
  • A Transition
  • Payment Policy and Work Force Composition
  • Maintaining Quality Standards
  • DME Summary
  • IME Issues
  • Modification of Medicare IME Funding
  • IME General, Non-Medicare Payments
  • Ambulatory Training
  • IME Summary and GME Conclusions
  • DME for Nursing
  • Allied Health
• Additional Issues
  • Openings, Mergers, and Acquisitions
  • A Medicare-Only Fund
  • The Balanced Budget Act of 1995
  • The Current System
  • Vouchers
  • State Programs
  • Educational Consortia
• References
• Appendix A Letter to the Institute of Medicine from the Committee on Ways and Means
• Appendix B History and Current Status of Medicare Graduate Medical Education Funding
• Appendix C Public Comment on Graduate Medical Education Issues

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies, and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

Support for this project was provided by The Pew Charitable Trusts, with additional support provided by the Commonwealth Fund and Burroughs Wellcome Fund. The opinions expressed in this report are those of the Committee on Implementing a National Graduate Medical Education Trust Fund and do not necessarily reflect the views of the funders.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.