Bell, Hershey S. MD; Ferretti, Silvia M. DO; Ortoski, Richard A. DO
For the past decade, medical student interest in a career in primary care has been declining. Since 1997, there has been a steady decrease in the number of graduating U.S. medical school seniors filling residency positions in family medicine, primary care internal medicine, primary care pediatrics, and internal medicine/pediatrics.1 Although osteopathic colleges of medicine traditionally have placed larger percentages of their graduates into primary care careers than have allopathic colleges of medicine, recent related trends within the osteopathic profession are disturbing. For example, whereas 37% of all graduates selected family medicine residencies in 1996, only 21.4% did so in 2004.2
Although the cause of this trend is multifactorial, it often includes issues of salary and indebtedness.3 Whitcomb,4 in an editorial commenting on the Working Group Report to the Association of American Medical Colleges (AAMC) Governance entitled Medical Education Costs and Student Debt, states: “I assert there is only one realistic way to do this (assuring an adequate number of highly qualified applicants to medical school): the length of the medical school curriculum must be shortened by one year.”
In work supported by the Agency for Health Care Research and Quality and the Robert Wood Johnson Foundation, Schwartz and colleagues5 articulate four strategies to increase medical students’ choice of generalist careers: (1) improving satisfaction and enthusiasm among generalist physician role models, (2) redoubling medical schools’ efforts to produce primary care physicians, (3) facilitating the pathway from medical school to generalist residency, and (4) increasing U.S. government funding for primary care research and training.
In this article, we describe how the Lake Erie College of Osteopathic Medicine (LECOM) positioned itself to address and implement the first three of the four strategies put forward by Schwartz and colleagues. We give special focus to their strategy regarding accelerated curricula.
Improving Satisfaction and Enthusiasm among Generalist Physician Role Models
In 2001, through the Title VII grant program of the federal Health Resources and Services Administration, LECOM established a department of primary care education. This is a collaborative unit comprised of what had been the department of family medicine, the division of general internal medicine, and the division of general pediatrics. The department of primary care education is now the most highly visible educational unit at LECOM. It includes the largest number of faculty in the school. The school president, dean, associate clinical dean, and associate dean for faculty development and evaluation are all members of the department. Department faculty members have significant teaching responsibilities in all courses offered by the school. The department chair is a practicing family physician who also directs the clinical skills education for all medical students. Because the department of primary care education is such an integral part of the school as a whole, those faculty members who act as generalist physician role models have been given more prominence at LECOM, with the expected consequence of increasing their satisfaction and enthusiasm.
Redoubling Medical Schools’ Efforts to Produce Primary Care Physicians
Recruiting future primary care physicians
LECOM has always kept its foundation of primary care in mind when recruiting students. The school’s Web site proudly displays the tagline, “Preparing the next generation of primary health care professionals.” From its mission statement, a stated LECOM goal is “to educate and develop primary care physicians who will practice in the osteopathic tradition.” However, with the establishment of the department of primary care education in 2001, LECOM took the first step towards accomplishing its goal of producing more primary care physicians by developing and implementing an accelerated primary care curriculum track, which is described below.
After their admissions interviews, all suitable applicants are offered acceptance to one of LECOM’s three existing four-year pathways—lecture/discussion (LDP), independent study (ISP), or problem-based learning (PBL). Accepted students who express interest in the accelerated curriculum then complete a second application, which focuses on two key considerations: (1) evidence of educational maturity as demonstrated by a willingness and ability to succeed in complex and rigorous coursework, and (2) a demonstrated commitment to enter primary care on graduation from medical school. On the basis of the information provided in the second application, a limited number of students will return for an interview with the accelerated curriculum admissions committee. Twelve of these students will be selected to matriculate as candidates for the accelerated curriculum. They will all be assigned the accelerated curriculum director as their advisor, to facilitate a firsthand assessment of their suitability for the accelerated curriculum during their first three months of study. In the first year of the program, only the six students who are best able to demonstrate the academic performance and attitudes consistent with predictors of success for the accelerated curriculum will be permitted to proceed with the accelerated curriculum; otherwise, they will continue in their initially chosen four-year pathway. During the first four years (2007–2010) of offering the accelerated curriculum, this number will be increased toward the full complement of 12 students.
The accelerated curriculum
On April 30, 2006, the American Osteopathic Association Commission on College Accreditation approved LECOM’s accelerated three-year medical school curriculum designed to encourage and facilitate students’ choice of a primary care career. The first students will begin the curriculum in October 2007 when the original 12 enrollees are pared down to six following the common anatomy course completed by all LECOM students. The goals of the accelerated curriculum, in response to the expressed financial barriers to choosing a primary care career, are to (1) reduce the time involved in becoming a primary care physician by one year, (2) reduce the cost of a medical school education by saving tuition and living expenses for one full year of medical education, and (3) increase the lifetime earning potential of graduates by enabling them to enter practice one year early.
Offering students a choice when it comes to their medical education has long been a part of LECOM’s curriculum design. With three distinct curriculum pathways, each geared to specific learner types, LECOM students are able to choose among LDP, PBL, and ISP methods. The accelerated curriculum now provides the additional choice of a shortened duration of study.
An overview of the accelerated curriculum is presented in Chart 1. The accelerated curriculum offers a modified four-year osteopathic medical school curriculum in a three-calendar-year time frame. Students attend class year-round with two-week vacations at the end of the designated first and second medical school years. The designated third medical school year begins in the spring of the second calendar year. The designated third medical school year ends after the eighth clinical rotation, and the designated fourth medical school year begins with the ninth clinical rotation in the fall of the third calendar year. The distinction between the end of the third medical school year and the start of the fourth medical school year is critical regarding students’ eligibility to sit for the Comprehensive Osteopathic Medical Licensing Examination.
In the accelerated curriculum, all of the courses and modules adapted from the first and second medical school years of LECOM’s four-year independent study curriculum will be preserved. These are presented in List 1. As presented in List 2, 11 rotations in the third and fourth medical school years are maintained from the existing clinical curriculum, five new rotations will be added, and 13 rotations have been eliminated for the accelerated curriculum. All clinical rotations will take place at one of five local “primary care centered” hospitals, to maintain proper educational and psychological monitoring of students in the accelerated curriculum. This also allows students to participate monthly in “capstone” case discussions at the LECOM campus using primary care cases to reinforce connections between basic sciences and primary care clinical medicine. A primary care mentor from the department of primary care education will be assigned to each student three months into the first year. Students will engage in patient care experiences with these mentors each month during the preclinical phase of the curriculum.
As mentioned above, rotations that do not occur in the four-year curriculum have been added to the accelerated curriculum. A clinical overview rotation was added to enhance students’ ability to prepare for board examinations. Students complete an osteopathic manipulative medicine rotation with a primary care physician to reinforce the philosophy and techniques used in primary care offices. Otolaryngology/ophthalmology replaces the general surgery 2 rotation of the traditional curriculum because of the prevalence of problems within these surgical subspecialties in primary care practice. A second medical selective was added to bring the total internal medicine experience to four months, the minimum that LECOM requires for undergraduate clinical studies. Finally, a subinternship serves as the final clinical rotation, replacing the primary care selective. It is anticipated that the subinternship will take place in the same hospital where the student matches for his/her primary care residency, to create continuity between undergraduate and graduate medical education.
Internal Medicine 3, Emergency Medicine 2, Surgery Selective, and Core Selective were eliminated in creating the accelerated curriculum because they were deemed nonessential to the generalist curriculum. Rural medicine was eliminated because we feel that the primary care emphasis of the LECOM accelerated curriculum will take into account rural medicine issues, given our location in primarily rural northwestern Pennsylvania. Finally, the six elective experiences were eliminated. The rationale for eliminating elective experiences is based on beliefs that to optimize the final year of medical school, schools need to deemphasize redundant and minimally effective “audition electives.”6
Education linked to the seven outcome competencies delineated by the American Osteopathic Association7 will be a unifying thread that runs through the entire accelerated curriculum. By exposing students to clinical primary care medicine early in their studies, by using case studies in the “capstone” experience, and by linking the undergraduate curriculum to the postgraduate curriculum with the final subinternship rotation, reinforcement of competency-based education will be possible. The osteopathic directors of medical education who were involved with the development of the accelerated curriculum advised that LECOM ensure that accelerated curriculum graduates demonstrate the same level of competency as graduates of the traditional four-year pathways.
LECOM views this accelerated curriculum as a “primary care scholars pathway” in that the students selected will be required to complete a rigorous curriculum in an abbreviated time-frame. They will receive additional mentoring and guidance befitting “scholars.” Students will also receive a scholarship equal to one year’s medical school tuition, provided they honor a commitment to remain in primary care for at least five years after graduation from residency. Because of the careful selection process, it is expected that most, if not all, students will succeed. If a student does experience failure in the accelerated curriculum, we expect that this will most likely occur during the preclinical segment. Because the student will be “ahead of schedule,” he or she will remediate, and then return to the four-year lecture/discussion or independent study curriculum at the corresponding time.
Facilitating the Pathway from Medical School to Generalist Residency
Initially, we considered a combined fourth-year medical student/first-year resident model for the accelerated curriculum to address Schwartz’s third strategy. Before a moratorium on its use in allopathic schools, this model had been successfully implemented as an experimental program in allopathic medical schools.8 Analysis of results from both the American Board of Internal Medicine and the American Board of Family Medicine concluded that students in these accelerated pathways performed no worse than students in traditional medical school programs. However, several concerns by LECOM Accelerated Curriculum Committee members prompted the consideration of an accelerated three-year curriculum model in place of a combined fourth year of medical school and first year of residency. First, uncertainty exists about the future possibility of a national standard requiring three distinct years of postgraduate training for licensure. Next, a number of health maintenance organizations require three years of distinct postgraduate training for credentialing. Finally, Medicare funding for a combined medical school/residency year is not assured. Because of the commitment of the directors of medical education at our core set of five training hospitals to the education and well-being of trainees during the transition from undergraduate to graduate medical education, we chose to use an accelerated three-year curriculum model directly linked, via a subinternship, to postgraduate education.
An additional factor in choosing the three-year approach is that LECOM has experience with accelerated curricula. LECOM’s School of Pharmacy is a three-year accelerated curriculum leading to the doctor of pharmacy degree. Only in its fourth year, the program ranks first in the number of applications received through Pharmacy College Application Service, suggesting its popularity with students. In this program, the curriculum is accelerated by using a 12-month schedule that offers 197 credit-hours across six semesters without sacrificing any of the core education required of a school of pharmacy.
LECOM has also formed successful articulation partnerships with local and regional undergraduate colleges. These partnerships accelerate the time necessary to complete medical education by allowing students to enter medical school after three years of college, provided they maintain a minimum academic standard and meet standards for acceptance to LECOM at the time of their initial application to undergraduate college. The aim of these programs is to allow gifted students an accelerated entry pathway into medical school. However, we believe that the students who come to LECOM through the articulation agreements are less likely to be the students who enter into the accelerated curriculum on the basis of their age and grades. Data suggest that students interested in primary care accelerated curricula tend to be older and to have grade point averages and medical college admissions test scores lower than the general medical school population.9
Can a Three-Year Accelerated Curriculum Be the Model for All Medical Students?
It is legitimate to ask, “Can this curriculum serve as a core curriculum for any medical student, regardless of eventual career interest?” The Faculty of Medicine at the University of Calgary, for example, offers a three-year curriculum that prepares students for all primary care, medical, and surgical specialties. An argument can be made that a four-year curriculum with elective experiences may allow a subset of students to gain maturity and solidify their eventual career choice; however, the number of students requiring four years to make a career choice, and the degree to which maturity and decision making are directly influenced by a four-year curriculum versus an accelerated curriculum, remain unknown and are certainly worthy of research. In LECOM’s case, when questions arose concerning curriculum decisions for the accelerated curriculum, our decisions emanated from the goal of ensuring that the pathway encouraged and facilitated a primary care career above all other career choices.
Worrisome trends have emerged in both allopathic and osteopathic medicine, such that the nation’s supply of primary care physicians is threatened. Issues of salary and indebtedness appear among the factors fueling the trend. Medical Education Costs and Student Debt, the working group report to the AAMC governance, states that “unless significant changes are made, careers in medicine may not be affordable or attractive within the next few decades.”10 Educational leaders have called for shortening the duration of medical education. Specific suggestions have been articulated to positively influence medical student choice of a career in primary care. LECOM has successfully positioned itself to respond to the three major nongovernmental strategies suggested by Schwartz and colleagues.5 Through the implementation of an accelerated three-year medical school curriculum, LECOM hopes to forward a national model that can reverse a decade-long trend away from primary care as a career choice.
Because the accelerated curriculum is an original approach to osteopathic medical education, it will be subjected to rigorous educational outcomes research conducted by the Teaching and Learning Center at LECOM. The evaluation will be conducted in four phases: matriculation data, undergraduate medical education performance, graduate medical education performance, and practice parameters. As evaluation results emerge, LECOM will share its experience with the larger academic community.
The authors wish to acknowledge the members of the accelerated curriculum Working Group: John M. Ferretti, DO (clinical professor of internal medicine and LECOM president), Robert George, DO (clinical professor of family medicine and associate dean of academic affairs at LECOM–Bradenton), Dennis Agostini, PhD, DO (professor of emergency medicine/biochemistry and associate dean of clinical education), Christine Kell, PhD (professor of microbiology and associate dean of preclinical education and student promotion and retention), Walter Buck, PhD (professor of anatomy and director of lecture–discussion pathway), Philip Hultgren, PhD (professor of physiology and coordinator of graduate studies), and Mark Andrews, PhD (associate professor of physiology and director of independent study pathway). The authors also wish to acknowledge the many members of the osteopathic medical education family who contributed, through focus-group discussions, to the final version of the curriculum. Finally, the authors are grateful to Lawrence L. Gabel, PhD, for his editorial advice.