Norris, Tom E. MD; Coombs, John B. MD; House, Peter MHA; Moore, Sylvia PhD, RD; Wenrich, Marjorie D. MPH; Ramsey, Paul G. MD
Physician workforce predictions have influenced the expansion and contraction of the number and the capacities of medical schools throughout the history of U.S. medical education. Recently, influential medical organizations have called for a 15% increase in medical school enrollment by 2015,1–3 and some discussions call for a 30% increase.4
Strategies to address anticipated workforce shortages in the early 21st century included expanding medical school enrollment and graduate medical education (GME) positions, as well as increasing the number of medical schools and residency programs, especially in underserved areas.3
Federal policies and subsidies fueled the expansion of medical school growth in the 1960s and 1970s. Such subsidies are not being seen in the current period, so the costs of expansion will be a major problem. In efforts to be cost-effective, medical schools have developed alternative models for expansion, such as regional campuses, collaborative arrangements, and incorporation of community-based faculty into teaching roles.
In this article, we review past medical school expansions and key models to address projected shortages. In particular, we describe how the University of Washington School of Medicine (UWSOM) uses a regional model, the WWAMI (the acronym for Washington, Wyoming, Montana, Alaska, Montana, Idaho) program to provide medical education for a five-state area without construction of new medical schools.
Historical Fluctuations in Numbers and Enrollments of Medical Schools
Physician workforce predictions have varied widely over the last 60 years. From concern about physician shortages after World War II through the 1970s, to predictions of surpluses in subsequent decades, to current concerns about likely future shortages, workforce predictions have influenced expansion and contraction patterns of existing schools and development of new schools. Throughout the history of medical education, the nation has lacked an optimal number, mix, and geographic distribution of physicians. The maldistribution of physicians has affected rural areas disproportionately, and there has been a consistent need for primary care physicians in rural settings for many decades.
The number of medical schools has also varied widely (Figure 1). In 1910, there were 131 U.S. medical schools.5 The Flexner Report, released in that year and calling for quality over quantity, led to substantial closures. By 1930, 76 medical schools remained, and the national physician-to-population ratio declined. Before and after World War II, new medical schools were built, including UWSOM.6 Later, demand for physician education increased, both from applicants seeking spots in medical school and from patients in underserved regions. In the late 1950s, a shortfall of nearly 40,000 physicians by 1975 was predicted; recommendations called for increases in medical-school graduates from 7,400 per year to 11,000 per year.6 Congress responded favorably, providing federal matching funds for construction of new facilities for existing schools that increased their entering class sizes.
Construction of new medical schools, coupled with larger enrollments at existing schools, increased the numbers of physicians nationally. Medical schools built between 1960 and 1980 were primarily community-based medical schools, often created to train primary care physicians.5,7 By 1980, 125 medical schools were operating—nearly the number in existence at the time of the Flexner Report. Florida State University College of Medicine, which opened in 2001, has been cited as the first new allopathic medical school in 20 years.8
Contemporary Calls and Plans for Increases in Enrollments
Current calls for expanding medical school enrollments emanate from physician workforce trend analyses by influential national organizations, including the Association of American Medical Colleges (AAMC), the American Medical Association (AMA), and the Council on Graduate Medical Education (COGME).1–3 Shortages are predicted for both primary care physicians and specialists. National recommendations call for development of medical school and residency positions in or adjacent to physician shortage/underserved areas, in undersupplied specialties, and in areas of rapid growth.1,3 A recent report from COGME calls for a 15% increase in total enrollment in U.S. medical schools from their 2002 levels over the next decade and an increase in the number of physicians entering residency training each year from approximately 24,000 in 2002 to 27,000 in 2015.2 The current level of activity at medical schools is likely to yield an increase of 5% to 8% in additional graduates by 2015.9
Models for Expansion
Anticipated models for expansion include increasing existing medical school enrollment, building new schools, and adding campuses or regional sites. A 2004 survey of deans at the 125 allopathic medical schools demonstrated that 31% of the 118 responding schools had already expanded or would definitely or probably expand class size in the next six years, which would result in a 4% increase in graduates.10,11 Another 20% of deans (23 schools) said an increase was “possible”; 47% (55 schools) responded “definitely” or “probably not.”
The 2005 entering class had more than 17,000 students, a 2.1% increase over 2004 figures, indicating that enrollment increases are under way.12 Twenty-two allopathic schools expanded class size by at least 5%; seven of these expanded first-year enrollment by more than 10%.12 Based on information from deans, the AAMC concluded that by 2010, the nation’s allopathic schools are likely to increase the number of graduates by at least 4.5% (to 17,278) and by as much as by 7.3% (to 17,928).9 Barriers cited to increasing enrollment included concerns about high and unrecoupable costs, especially among public schools dependent on tight state budgets, not enough preceptors in ambulatory settings, and limited labs, study space, and clinical training sites.
Among 56 medical schools indicating a “definite” or “probable” enrollment increase, expansion of existing facilities was the most likely method.11 Sixty-six percent (37 schools) chose new clinical affiliations as a mechanism to increase enrollment. Fifty-two percent (29 schools) were considering expansion of existing campuses to accommodate enrollment expansion. Nineteen (34%) considered this a definite option. Sixteen schools (29%) reported a new satellite/regional campus as an expansion option, and five (3%) called this option definite. Below, we discuss regional expansion as an option and our own experiences with that approach.
Regional Expansion: History and Opportunities
Status of regional expansion
A 2003 AAMC report on regional campuses cited a number of existing definitions of regional campuses.13 By the definition used in the report (geographically separate and not the medical school’s primary clinical site for education; has administrative ties to the dean’s office and not simply a department tie; and offers at least four required third-year clerkships), 41 regional campuses were identified at 25 medical schools. Several others were slated to open in subsequent years. Twenty-five medical schools (which will be 27 by the time this article is published) had at least two campuses: a main campus and one or more regional clinical campuses, where third- and fourth-year medical students are educated. The report did not cover in detail those with regional basic-science campuses within existing state universities.
Six medical schools were cited as having basic-science branch campuses without clinical activity: Indiana University School of Medicine, with eight branch campuses; David Geffen School of Medicine at UCLA, with one branch campus; University of California, San Francisco, School of Medicine, with one branch campus; University of Illinois at Chicago College of Medicine, with one branch campus that is also a clinical branch campus; University of Minnesota Medical School, with one branch campus; and the University of Washington School of Medicine, with five branch campuses.
Advantages of regional expansion
Branch, or regional, campuses were seen as increasing enrollment in a cost-effective fashion, increasing clinical training opportunities and sites, especially ambulatory training sites, expanding graduate medical education (resulting in the need for more teaching patients), and responding to health care needs of surrounding regions and underserved populations.13
A major detriment to starting a new medical school is the cost. The 1970 Carnegie Commission on Higher Education called for a 50% increase in the number of first-year medical students by 1978, and called for nine new university health-science centers.13 Six of the nine cities cited as needing new medical schools opted instead to develop regional, or branch, campuses. As the AAMC report notes, this underscores the difficulties in starting new medical schools, including high start-up costs, local and state politics, and reluctance of existing medical schools to support new competition.13 The most recent medical school to be built, at Florida State University, cost $155.5 million for facilities and operating revenue.8 The state annual operational funding at full roll-out is expected to be $38 million a year.
Models of regional expansion
Although the AAMC report focused on regional campuses that offer at least four required third-year clerkships, there are a number of regional models. The most common teaches basic sciences at a central medical school and offers clerkships at regional centers. Examples include Florida State University College of Medicine, University of North Dakota School of Medicine and Health Sciences, University of South Dakota School of Medicine, and Michigan State University College of Human Medicine.
Another model involves offering part or the entire basic science curriculum regionally with clerkships both centrally and regionally. Indiana University has eight branch campuses for medical education that provide first- and second-year medical school programs; all students complete clinical training at the Indianapolis campus.
The University of Washington’s WWAMI model represents another variation. First-year basic sciences are offered at the Seattle campus and five regional campuses; students attend their home state campus. For the second year, all medical students train in Seattle. In the third and fourth years, clerkship sites are located in Seattle and throughout the five-state region; medical students choose where they complete their rotations. The section below describes WWAMI in more detail, including consideration of plans for further expansion.
WWAMI Expansion: Past, Present, and Future
History of WWAMI and infrastructure
The WWAMI program’s inception, history, and development have been described elsewhere in detail.14 Briefly, the regional program was developed in the early 1970s as a cost-effective solution to health provider and health care shortages in Northwest states without medical schools. The program increased the number of publicly supported medical school positions in a well-established, high-quality medical school (UWSOM) without the major capital construction associated with building new medical schools and without adding significant numbers of new faculty. The primary care focus and significant time each student spends in his or her home state increases the likelihood of returning to practice in one’s home state. Each WWAMI state has well-regarded state universities from which most basic science faculty can be drawn for teaching first-year medical students. The different components of the program are described below.
Existing state universities serve as first-year academic basic-science sites. These include the University of Alaska at Anchorage (Anchorage—10 students trained per year), Montana State University (Bozeman—20 students), the University of Idaho (Moscow—18 students), and University of Wyoming (Laramie—14 students). Washington residents spend their first year at the Seattle campus (100 students) or at Washington State University-Pullman (20 students), in which case they study with their classmates at nearby University of Idaho.
Students from each regional first-year basic science campus train in Seattle at the UWSOM campus, receiving intensive contact with clinically based academic physicians and physician-scientists in basic-science classes in the integrated organ-system structure. All students receive an intensive introduction to clinical medicine (a continuation of a first-year course at regional campuses) that brings them to the bedside for one half-day each week, working with a faculty mentor and small group of medical students.15 Faculty mentors maintain contact with their student groups until graduation.
UWSOM has affiliations with over 3,000 individual physicians in over 170 active community-based educational sites throughout the five states to teach students in the required and elective clerkships. Settings include community clinics, private practices, and affiliated hospitals. Students choose a combination of states and sites for required and elective clerkships; some spend most of their time in Seattle, others spend considerable or most of their time at regional community sites. Clerkships are hospital-based, ambulatory-practice based, or a combination.
Some states have developed “tracks” or clinical education centers where students complete most or all of their third-year clinical education within a single state. Such tracks are currently offered in Boise, Spokane, and Anchorage, and will eventually be offered in Montana.
Expansion to Wyoming
The first addition of a new academic site since the program’s inception was at the University of Wyoming in Laramie. This site began in 1997, training 10 students per year. The regional campus developed in the context of an existing College of Health Sciences established in 1984. The Wyoming legislature has expanded its support of the program by passing a bill increasing Wyoming’s participation.16 The bill allows the state to increase its portion of the WWAMI program to as many as 16 students by 2007. Clinical training sites in Wyoming begin in 1998.
The successful involvement of Wyoming physicians across multiple clinical sites resulted from early attention to building partnerships and formal agreements with the Wyoming Medical Society and the University of Wyoming. A Wyoming physician has been hired to work as the clinical coordinator. The visibility of WWAMI students serving in clinics and hospitals across Wyoming has strengthened support from the Wyoming legislature, and Wyoming views WWAMI as its medical school.
WWAMI Expansion: Interest, Plans, and Challenges
Expansion in existing regional sites
Periodically, the WWAMI states have expressed interest in expanding the number of medical students at their first-year sites. Discussions on possible expansion have occurred recently in Wyoming (expansion now under way), Montana, Idaho, and Alaska.
Current interest in a new first-year site
In 2003, the community in Spokane, eastern Washington’s largest city, started a dialogue with the UWSOM for a new first-year site there. Initially interested in a separately accredited school of medicine, the community became more interested over time in joining WWAMI. The community identified the goals of increasing the number of physicians trained in the Spokane area, thereby increasing the supply of physicians in the state, with particular emphasis on Spokane and eastern Washington; responding to the need to train physicians for underserved rural areas in Washington; and increasing local support for biomedical research and, correspondingly, increasing economic development and new industry. UWSOM’s dean called for a feasibility study, now completed; on July 21, 2006, a formal announcement of intent to seek state funding for this expansion was released by the University of Washington, UWSOM, Washington State University, and legislative leaders. A new site would initially accommodate an additional 20 students per year.
Challenges associated with initiating a new site
WWAMI regional administrators have identified several challenges to consider when initiating a new regional site:
Creating basic-science programs away from the medical school site.
Preclinical medical students require faculty with scholarly backgrounds who can teach these students the clinical implications of the basic science subjects they are learning. Medical students, both preclinical and clinical, are a different student population from graduate students and residents, and appropriate instructors must be identified. This sometimes means recruiting outside of existing faculty.
Financial and physical plant challenges.
Total costs to initiate and implement a regional site are not nearly as extensive as those needed to start a new medical school, but start-up costs and educational space still must be considered. In Spokane, which has a relatively new and not fully occupied health sciences campus, capital expenditures are needed to initiate a willed-body program, upgrade the gross anatomy lab, provide microscopy/histology materials, recruit faculty, and provide funds for six new faculty, lab leases, equipment, and lab personnel. Research space must be identified to recruit basic science faculty. The program would also expand needs at the Seattle campus. Start-up and operating costs involve expansion of lecture halls, small-group teaching, and teaching and anatomy spaces to accommodate second-year Spokane students. This may or may not be needed for other medical schools, but the UWSOM has reached the limit of its ability to accommodate medical students in existing facilities.
For expanded clinical education, sites for an additional 20 students per year must be identified throughout the five states; presumably, the majority will be in the Spokane region. In an age of increased productivity demands on clinicians, finding community-based clinical teachers to serve as preceptors and clerkship instructors is challenging. This strong commitment requires teaching skills and willingness to undergo faculty development training.
Research at regional sites.
The new medical schools created in the 1960s reported difficulty being accepted by their traditional counterparts, in part because of their preoccupation with educational issues and modest funding of research.7,13 Many regional clinical campuses, which focus almost entirely on clinical teaching with little or no research enterprise, faced similar challenges. In the WWAMI states, expectations for research activities have grown and are an important part of the program for regional partners. In 2002, the total external research funding for WWAMI faculty ranged from $2.5 million to $14 million per year per site from a variety of federal and private sources. As a result of these successes, conduct of research has become an expectation among WWAMI first-year sites, along with the expectation of related regional economic development.
A significant challenge in expanding or establishing a regional site is ensuring educational equivalency, mandated by the Liaison Committee on Medical Education. UWSOM embraced equivalency upon inception of the WWAMI program and has focused on it consistently. The University of Washington Department of Medical Education tracks students closely and helps assure and demonstrate educational equivalency.14,17 Frequent meetings and trips by UWSOM faculty to first-year and clinical sites, along with annual retreats, are mechanisms for training and ensuring equivalency of approach. Careful evaluation occurs through common exams across all sites and at regular grading and curriculum meetings with clerkship directors and teachers from all sites.
Challenges and rewards for regional clinical faculty.
Volunteer faculty must meet their own clinical practice needs and achieve satisfaction and value from faculty activities. To that end, UWSOM conducted surveys of regional clinically-based volunteer faculty in 2000 and 2005 to assess challenges and satisfaction associated with clinical teaching.
Community-based clinical faculty experience both rewards and challenges (see Figures 2 and 3). Survey responses from 268 faculty from throughout the five-state reason in 2000 indicated that the negative impacts of teaching students were relatively minimal compared with the positive impacts. In 2000, the greatest negative impact was on productivity (27% rated a negative impact), followed by workload (26% rated a negative impact). Income was third; 16% rated the impact on their incomes of teaching students as negative. In 2005, 44% of 259 respondents assessed a negative impact of teaching students on workload, 37% assessed a negative impact on productivity, and 28% assessed a negative impact on income.
Across both the 2000 and 2005 surveys, the greatest positive impact was seen in achieving professional goals (85% in 2000 and 88% in 2005 rated serving as a clinical teacher in the WWAMI program as having a strong positive impact on professional goals in their practices). In 2000, other areas in which clinical faculty assessed a positive impact on their practices were office operations and staff (60%), patient care (58%), and colleague relations (57%). In 2005, clinical faculty also assessed positive impact on their practices in relationships with colleagues (75%) and keeping current (81%; this factor was not assessed in 2000).
Students’ reactions to the regional program are consistently positive, as judged by graduating students’ responses to the open-ended question, “Please comment on what you perceive to be the strengths of your medical school,” tabulated from the AAMC graduation questionnaire for the years 1995 through 1998 and 2002. The WWAMI program, with its first-year and clerkship components considered together, received the highest number of positive comments for three of the five years, and the second most comments for the other two years. Comments in 1999–2001 and 2003–2005 were similar to these.
Medical schools will likely expand over the next 10 years, whether through expansion of existing schools, construction of new schools, or development of regional campuses and programs. Based on surveys of medical school deans, it appears likely that all those models will be utilized. Construction of schools is an enormous undertaking that frequently costs over $100 million; high start-up costs and extended development time are inevitable.8 However, there may be compelling reasons in some settings to initiate new schools. Expansion in existing space works well when space, facilities, teachers, and clinical teaching sites permit or resources are available for expansion. Another option is regional expansion.
The University of Washington School of Medicine WWAMI program has expanded medical education into four surrounding states. Regional expansion was completed without construction of new buildings, campuses, or centers. The program relies on collaborative relationships with existing state universities and faculties for preclinical basic-science education, and on volunteer regional clinicians for clinical education. Participating clinicians hold clinical faculty status and receive the benefits, training, and requirements commensurate with that status; they teach, monitor, and mentor students in their practices, whether hospital-based or practice-based. Several University of Washington affiliate hospitals located regionally, such as the Boise Veterans Administration Hospital in Boise, Idaho, permit more concentrated basic and elective clerkship activities in and around that site.
Key challenges to the regional model also represent strengths. Those that we have encountered include (1) meeting the unique needs of each region; (2) ensuring educational equivalence; and (3) maintaining interest in, attention to, and unity among program participants across a diverse geographic spread. While preserving this unity is a challenge, we have evidence that, on the whole, our volunteer faculty greatly benefit from their work with WWAMI. The positive effects of teaching students on clinical practice generate loyalty among regional volunteer faculty, as do the clear signs that the WWAMI program is having a positive effect on correcting shortages and maldistribution of physicians in these rural states. These elements, in turn, strengthen the entire WWAMI program.
The WWAMI program was developed to respond to the needs of the surrounding states, all of which were medically underserved and none of which had their own medical schools. Participating states aimed to have medical students return to practice in their home states, and this has been achieved. UWSOM has a high retention rate for students who ultimately practice in their home states. Return rates of students in each of the WWAMI states have been well above the national average. State needs change over time, as evidenced by the Spokane community’s interest in a new first-year WWAMI site. The nature of those interests may shift; one of the Spokane community’s interests, in addition to increasing the number of future physicians in their region, is promoting biomedical research and related areas as an economic priority for their region. Thus, considering a new site in Spokane must strongly consider this aspect of regional campus development planning.
A focus on partnership among all participants is a key factor in the WWAMI program’s success. Continued evolution of the program is another important factor, with careful development of new ideas, such as the WRITE program (which stands for WWAMI Rural Integrated Training Experience), which gives a small number of students sustained exposure to a rural community in third year.14 This evolution helps keep the program fresh and contemporary. The focus and evolutionary development of an educational continuum that considers the needs of undergraduate medical education, graduate medical education, continuing education, and recruitment to health careers in K–12, has helped maintain strong interest in and awareness of the relevance of the program to regional communities.
The Value of Regional Approaches
The reasons to consider regional campuses and regional programs are many. At the top of the list is their cost-effectiveness, making use of and carefully building on existing resources to assure a combination of high quality and low cost. Given the important challenge of containing health care costs, efficiency and cost-effectiveness are imperative. Building on an existing successful program has the potential to save money, spread the strengths and lessons of that program to new regions, and build community and cohesion region-wide. The enthusiasm of the medical students in the WWAMI program for the education they receive and the enthusiasm of the regional WWAMI faculty for the way the program helps them stay current and develop and enhance collegial relationships speaks to the success of that program and of the regional education approach it embodies.