Porter, David D. MD
Dr. Porter is professor emeritus, Department of Pathology and Laboratory Medicine, University of California, Los Angeles, UCLA School of Medicine, Los Angeles, California.
The poor quality or nonexistence of clinical teaching in the mid-19th century was, or should have been, an embarrassment in American proprietary medical schools. The problem was corrected by the development of the Johns Hopkins University School of Medicine and other university-associated medical schools in the decades before and after the 1910 Flexner report.1 However, in recent decades, new barriers to clinical teaching have arisen. In this Commentary, I indicate what these barriers are and suggest how changes may be made to revitalize clinical education.
MODERN BARRIERS TO CLINICAL TEACHING
Increasing Size of the Academic Clinical Enterprise
In 1920, the numbers of medical schools and students graduated were 86 and 3,047; in 1960, these numbers were 86 and 6,994. In other words, the number of students doubled, but the number of schools stayed the same (although during this time, some had closed and new ones had replaced them). However, growth in the numbers of both students and schools continued after 1960, so that by 1997–98, there were 16,165 students accepted into 125 accredited medical schools, and it can be anticipated that all but a handful will graduate. As for numbers of faculty, in 1960–61, there were 11,224 paid full-time faculty, or an average of 131 per school, of whom 7,201 were in clinical departments. In contrast, in 1996–97 there were 95,440 paid full-time faculty, or an average of 764 per school, of whom 78,233 were in clinical departments.2 It appears that the astonishing increase in size of the clinical department faculty has, paradoxically, been accompanied by a decrease in clinical teaching. This has occurred since most of the new faculty were hired to perform patient care, rather than teach.
Medicare Changes the Financial Rules
Passage of Medicare in 1965 completely altered the financial landscape for medical education, teaching hospitals, and faculty salaries. Prior to Medicare the medical schools were funded by tuition, donors, and in some cases local and state governments. Before 1965, patient care in an amount sufficient to train students and residents was mostly done with charity patients, often in university-affiliated rather than in university-owned hospitals. What has happened in the intervening 35 years? Spending for Medicare has increased from $22 billion in 1977 to $215 billion in 1997, while the population eligible for coverage increased from 26 to 39 million. It is generally accepted that academic hospitals have costs about 30–40% higher than those of non-teaching hospitals. The excess costs include the actual wages of residents, increased utilization of the laboratory and supplies by the trainees, and the inefficiency of having less than fully trained and maximally productive people around. Trainees may not be the only cause of high costs in academic medical centers. It is also clear that patients who have difficult and expensive-to-treat diseases will disproportionately select care at these centers.3 Medicare has indirectly contributed to the teaching changes by markedly increasing faculty salaries and thus demands, and by making the provision of large amounts of patient care remunerative to the medical schools and associated hospitals.
Focus on Money
In the environment of managed care, many of the medical schools and associated hospitals have purchased physicians' practices, community hospitals, and clinics in an attempt to gain market share. At one school that I visited, over 200 primary care physicians had been added to the faculty, but lamented that they had no time to teach because the system was striving to make them financially efficient. I have heard several clinical departmental chairs say that medical student teaching is a complete financial loss, and it would be better to have the voluntary clinical faculty teach students so the university faculty could bring in more practice money. As it is, in clinical subjects the medical students are probably taught appreciably more by residents and fellows than by the faculty. A spectacular recent book by Ludmerer4 reviews the last century of medical education with an emphasis on the recent problems, but is more analytic than prescriptive.
The high and increasing cost of hospital care in general, and university hospitals in particular, has raised political alarm and brought on numerous efforts to control costs. These efforts have resulted in much shorter hospital stays, so short that there often is not enough time for the education of students and residents. Since 1965, the federal government has given specific funds for graduate medical education. The cost of medical education in teaching hospitals, mostly for residents rather than medical students, was estimated to be $18 billion in 1997, of which the federal government paid $8.5 billion, $7.1 billion of it via Medicare. This leaves the universities and hospitals to scramble for the difference, and for essentially all the costs of undergraduate clinical training. Further, the Balanced Budget Act of 1997 threatens to markedly reduce the federal contribution to clinical teaching. Although a strong case can be made for public funding of clinical education, there appears to be no compelling reason for it to be based in the Medicare program. It should be noted that the failed 1994 Clinton proposal for health care reform would have taxed all payers for the cost of clinical education, but insurance companies resisted this point strenuously. The situation in the United States is thus unlike that in most of the rest of the world, where the medical schools and associated university hospitals are supported by government single-payer systems.
HOW CHANGES MIGHT BE MADE
Urgent problems facing medicine include the uninsured and indigent, emergency care, cost containment, and quality of care in addition to the clinical teaching problem. But I maintain that the clinical teaching problem should be solved first. How do I justify trying to do that? Mainly it is because I believe that the teaching problem is susceptible to a reasonable solution over fewer years and at a lower cost than the other problems.
What must be done to make the needed changes in clinical medical education happen? It is clear that the legislatures and Congress are unwilling to take the political risks that a reform of the provision of medical services, possibly involving a single-payer system, would require. The leaders of the medical schools and university hospitals have a vested interest in the status quo, and operate under the imperative “to keep the doors open at all costs.” Despite enormous time devoted to curricular redesign, a medical sociologist has written on the failure of such curricular reforms to result in change.5 Yet without change from within, I believe that larger changes will be forced from out-side.
The most urgent change needed is to secure stable long-term funding for clinical education at both the medical students' and the residents' levels. This appears to require a uniform national policy and financial support by all purchasers of medical care, and thus would need Congressional action. Medical students, residents, and academic and practicing physicians should conduct a concerted campaign for this change. Additionally, faculty need to demonstrate their willingness and enthusiasm for teaching, and the administrators of the medical schools and hospitals must indicate by their actions that they value teaching.
1. Ludmerer KM. Learning to Heal. The Development of American Medical Education. New York: Basic Books, 1985.
2. Jolly P, Hudley DM (eds). AAMC Data Book: Statistical Information Related to Medical Education. Washington, DC: Association of American Medical Colleges, 1998.
3. Bailey JE, Van Brunt DL, Mirvis DM, et al. Academic managed care organizations and adverse selection under Medicaid managed care in Tennessee. JAMA. 1999;282:1067–72.
4. Ludmerer KM. Time to Heal. American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press, 1999.
5. Bloom SW. Structure and ideology in medical education: an analysis of resistance to change. J Health Soc Behav. 1988;29:294–306.