Robertson, Joseph E. Jr MD, MBA; Boyd, Jennifer PhD; Hedges, Jerris R. MD, MS, MMM; Keenan, Edward J. PhD
Oregon Health & Science University (OHSU) School of Medicine (SOM), Oregon's only medical school, needs to educate a robust and well-qualified provider workforce to meet the state's health care needs. Faced with the growing problem of Oregon's insufficient physician workforce, a situation worsened by maldistribution of physicians, the OHSU SOM is implementing a four-phase plan to increase medical school class size through partnership with state universities, health care systems, and community physicians. To date, the plan has been reproducible, on target, and on budget. Following is an overview of how our comparatively small and financially limited medical school is in the process of doubling the size of the graduating class.
Oregon's Physician Workforce
Oregon faces the same projected physician workforce shortage as the rest of the country—forecasts of an inadequate supply and worsening maldistribution. Oregon's population (3,700,758 in 2006) is growing faster than its number of licensed, active, and practicing physicians (9,848 MD/581 DO in 2006). Oregon's rural areas, defined as geographic areas 10 or more miles from a population center of 30,000 or more, are less well served by the current physician workforce than its urban areas, and Oregon's physician workforce is aging. The workforce—especially in nonmetropolitan and rural areas—is not adequate now and will be grossly inadequate by 2020.1
Multiple surveys of Oregon physicians establish that physician retirement is outpacing replacement. Oregon's population of individuals 65 and older, estimated at nearly 424,000 in 2002, is projected to increase to more than 936,000 in 2020.1 More Oregon physicians are now in the 51 to 60 age group than there were in 1994, and fewer are in the 41 to 50 group—a trend evident, but not nearly as remarkable, in the general population.2 Oregon also has physician shortages and maldistribution in multiple specialties, including rheumatology, nephrology, gastroenterology, cardiology, and allergy immunology. In addition, estimates now show 15% of Oregon's physicians in part-time practice or in government or administrative positions. This means that only 85% of the physician workforce is available to serve patients.2
More than 13% of Oregon's physicians (about 1,250) exited the workforce between 2004 and 20063; during this same period, the OHSU SOM graduated about 300 new physicians. Furthermore, assessing what will be needed to constitute an adequate future workforce is made even more difficult by a steadily increasing trend among both female and male medical graduates to opt for specialties with controllable lifestyles.4 The given, however, is that on the basis of current trends and conditions, the supply of physicians practicing in Oregon within the next two decades will very likely be inadequate to meet the population's demand for both primary and specialty care.
Increasing Medical School Enrollment
The number of graduates from U.S. medical schools in the past 20 years has remained fairly constant (16,343 graduates in 1983–1984 compared with 15,821 in 2003–2004).5 During the same period, the number of graduates from OHSU SOM actually decreased (110 in 1983–1984 compared with only 86 in 2003–2004). Since 2001, however, entering class size has been incrementally increased from 101 in 2001 to 120 in 2006 in accordance with our four-phase plan, which is detailed below. To date, class size has been increased to the maximum number of students that can be accommodated in the current basic science laboratory facility and in clinical sites on the OHSU campus and in the Portland metropolitan area. Because of this cap on growth at OHSU and in Portland, the school adopted a plan to regionalize medical education, to increase the number of students further.
But merely increasing the number of medical school graduates will not adequately address the problems inherent to providing care to a growing population of elderly, underinsured, and underserved patients in upcoming years. As in most states, Oregon's impending physician shortage, both for primary and specialty care, will be most pervasive in rural and underserved areas. As a geographically large state with approximately half its population—and 55% of its physician workforce—centered in the Portland metropolitan area, Oregon is challenged to address health care needs throughout the state as well as to meet the needs of the underinsured in urban areas previously supported at a higher level by the Oregon Health Plan, which uses federal Medicaid money to provide health care coverage to low-income Oregonians.
Beginning in 2001, the OHSU SOM was faced with a dilemma: its obligation to educate additional physicians needed by the state, despite the limitations of a constrained budget. The school, although in the top 20% for biomedical research funding as reported in the 2005 National Institutes of Health ranking of medical colleges, is in the bottom five of publicly assisted medical colleges with regard to state appropriation. This situation resulted in our adopting a four-part plan that minimized capital expenditure while leveraging existing resources at OHSU.
Expanding the SOM
We identified three criteria as paramount in developing a workable expansion plan for the OHSU SOM: enhancing the supply of medical graduates as the demand increases, improving the ethnic and cultural diversity and the geographical distribution of physicians throughout the state, and deriving community support by creating a community-based collaborative. Efficiency, economy, and timeliness were noted as key considerations. The four-phase plan addresses all of these criteria:
Phase 1 of the plan (2001–2006) used only resources of OHSU's capital budget to increase enrollment incrementally by adding four students per entering class at the SOM's Portland site. This resulted in an entering class of 120 students in fall 2006—an increase of approximately 20% compared with the 2001 entering class size.
Phase 2 (2006–2007) creates community partnerships with providers, health systems, and universities throughout the state to develop regional sites using the physical facilities of these partners, again avoiding the need for capital investment. Additional capital is provided through philanthropic partnerships with community institutions, taking care not to undermine the development effort currently supporting the SOM. Phases 1 and 2 must be completed in a manner where the additional cost per student does not exceed the generated tuition revenue.
Phase 3 (2007–2010) will continue to build on the prototype developed in Phase 2 and, through expanding the network of community partnerships, create additional regional educational sites.
Phase 4 is the long-term step (2010–2015). During this period, after a feasibility study and subsequent capital campaign, construction would begin on an integrated educational facility on the newly established Schnitzer campus, gifted land on Portland's south waterfront connected with the main Marquam Hill campus by the Portland Aerial Tram. Plans for a new medical school facility got a major jumpstart with an anonymous gift of $40 million, announced in February 2007.
Even when the goal of a new medical school facility at the Schnitzer campus is realized and a significantly increased enrollment of medical students (200 students/class) can be accommodated in Portland, the regional campuses established during Phases 2 and 3 will remain essential elements in ensuring an adequate physician workforce, enhancing physician distribution, and providing needed clinical training opportunities outside the Portland metropolitan area.
Stress on faculty and facilities, dilution of educational quality, and financial burdens that most medical schools are ill prepared to assume are all possible risks of increasing medical student populations. But at least 38 U.S. medical schools have successfully established regional campuses, beginning in early 1970,5 and much has been learned from their experiences. However, the OHSU SOM model for expansion is unique in that it accommodates capital constraints, provides flexibility and efficiency, and increases distribution of students and resources statewide through a community-based collaborative that includes major universities and health systems.
Expansion Through Public and Private Community-Based Partnerships
Currently, about 40% of clinical training for our medical students occurs outside of OHSU's facilities, albeit mostly within the Portland metropolitan area. Further, a rural outreach program is well established through the Area Health Education Centers (AHEC) program, a partnership program between OHSU and Oregon communities. The AHEC program has improved the distribution of health care professionals in Oregon and promotes relationships with local health care facilities and providers, community leaders, schools, and citizens to identify and meet local health care needs. The AHEC program offers support to several OHSU education programs, including its family medicine residency programs and its medical, dental, nursing, and allied health degree programs.
Barriers to expansion.
The commitment to expanding enrollment in the SOM quickly brought to light several barriers to expansion. Whereas the number of applicants to OHSU has increased by 62% since 2001, the Oregon resident applicant pool has been relatively constant for a generation. This poses a challenge to the goal of increasing the number of resident matriculants and addressing distribution issues, a challenge compounded by a relative lack of scholarships, space, and capital. However, pipeline programs that bring high school and college students to OHSU and take OHSU representatives to schools throughout the state are helping encourage and support potential future applicants.
The SOM administration identified partnership development through community-based medical education and outreach as the best strategy for timely expansion. Community partnerships provide faster response time and more efficient expansion opportunities than attempting to increase class size within the walls of the SOM alone. Growth within an existing structure is generally limited, and within OHSU's existing structure we are limited to increasing class size to 120 medical students, a goal realized at the Portland campus in 2006. Limitation to expansion of class size on the Portland campus is related primarily to the capacity of the anatomy laboratory facility and to the available number of clinical teaching sites on campus and within the community.
Increasing the class size using regional, community-based partnerships requires only a modest capital investment; at this level of saturation, financial forecasting is not done on an average cost-per-student basis but, rather, on a marginal analysis (i.e., the actual costs associated with each additional student, given the assumption that sunk costs have already been covered by revenue of existing students). Given this scenario, the additional costs associated with each student cannot exceed the tuition charged that student, absent any other source of additional revenue.
Partnering with State Universities and Community Health Systems
Because the relatively small increases in existing class size achieved in the last five years at the OHSU Marquam Hill main campus will not provide for adequate growth in the number of physicians produced to meet the looming need, the SOM has partnered with the University of Oregon in Eugene to establish the first regional campus. This site is adjacent to the University of Oregon campus and is located in a building owned by a regional health system, PeaceHealth, Oregon Region, which is OHSU's essential partner in providing clinical training venues.
PeaceHealth, with Sacred Heart Medical Center and PeaceHealth Medical Group clinics throughout Lane and Benton Counties, provides sites for clinical training for SOM students and offers significant business expertise in developing the regional campus. Many of the physicians currently in the PeaceHealth system and in the Eugene community have previously held faculty positions at a medical school, thus providing an important experiential base for developing a clinical curriculum and faculty at this location. Partnerships of this type among existing entities offer an efficient option for expansion and afford rapid response time for growth, shared risk, and shared resources. In addition, the Eugene SOM campus provides a model for other sites throughout Oregon.
Because existing faculty and facilities at the University of Oregon are being used, expansion to the Eugene campus requires minimal capital outlay. Expenditure of time and effort by OHSU and University of Oregon faculty members will be necessary to coordinate the curriculum and develop the faculty. In addition, some distance-learning methods will need to be developed by Portland-based OHSU faculty. For the most part, however, facilities—especially basic science laboratory space—are already in place in Eugene.
Initially, the identified sources for financing regional campuses were tuition and philanthropic efforts, but this plan has evolved somewhat. In 2005, the SOM received a $1.5 million grant from the James F. and Marion L. Miller Foundation to support program development for the Eugene initiative and the regionalization of medical education through a collaborative process. For further financing, in late 2006–2007, OHSU made a strong appeal to state legislators to fund a special workforce initiative through the state's biannual budget. Support from the PeaceHealth–Oregon System and medical staff support clinical rotations, and tuition dollars support the administrative, faculty recruitment, and accreditation oversight by OHSU. Faculty appointments at regional campuses will be shared between OHSU and the partner university. Overall, these initiatives are expected to be self-sustaining. The SOM will evolve the existing management structure to incorporate a collaborative model for regional campuses.
The SOM has now established clinical electives for fourth-year students and core clinical clerkships for third-year students in PeaceHealth facilities in Eugene and Cottage Grove (Lane and Benton Counties). The first-year medical school curriculum in Eugene is slated to be offered in the 2008–2009 academic year. The second year of the medical school curriculum, however, will be offered only at the OHSU Marquam Hill Campus in Portland, where the capacity for second-year medical curriculum is 160 students. This will ensure timely and appropriate progression of all students to the clinical curriculum through coordinating clinical skills development and assessment, solidifying class identity, and providing effective career planning and services for students. First-year students in Eugene will receive their longitudinal precepted clinical experience from PeaceHealth physicians.
The infusion of students and residents within health care systems throughout the state benefits Oregonians and their current care providers by exposing trainees to new clinical concepts and by imprinting students and residents with practice opportunities outside of the Portland metropolitan area. Given that trainees often choose to practice in areas where they have received their medical training, efforts to provide more training outside of Portland are essential to reversing the disparity in physician distribution.
Advantages of the State University, Medical School, and Health System Partnership
The three-way partnership for the prototype SOM regional campus in Eugene, now recognized as Oregon Medicine (ORMED), offers benefits for all parties. The University of Oregon will have better utilization of available space and faculty, will realize increased tuition revenue and visibility, and will have access to OHSU's educational and research resources. Partnerships between or with state-supported institutions enhance both the levels of state support, use of funded resources, and political strength in future negotiations.
Having a regional campus at the University of Oregon will enhance the university's premedical and graduate programs, provide the potential for MD/PhD programs in Eugene, and create greater opportunity for collaborative and translational research. In addition, medical students will benefit from the opportunity to pursue graduate programs at either OHSU or the University of Oregon.
PeaceHealth will also benefit by integrating OHSU medical students and faculty into its hospitals and clinics, and from the recruitment of future physicians to the PeaceHealth system. OHSU SOM will meet its immediate needs for expansion and additional clinical training opportunities, create a new philanthropic market and recruitment opportunities, and gain access to University of Oregon resources. In regard to the Eugene site, the medical school dean, University of Oregon provost, and PeaceHealth CEO will work as a collaborative management team (executive council), bringing together distinct areas of expertise and experience. The intent of the regional initiative in Eugene, however, will not be to establish a second medical school. The medical school course work at a regional campus will be offered under OHSU SOM's accredited status with the Liaison Committee on Medical Education, and all curricular and admissions program oversight will remain the purview of the OHSU SOM.
Establishing campuses in other parts of the state opens new opportunities for recruiting a larger population of qualified Oregon applicants. The issue of physician distribution and ensuring access to care in rural areas is best addressed in both recruiting the right applicant pool and then motivating those students to practice in the right locations. Bowman6 has established that rural heritage must be considered as a factor in creating diversity. More than 50% of allopathic medical students in the United States are born in counties with populations greater than 1 million, and, statistically, they are the least likely to choose primary care and rural practice.6 Graduates who grow up in rural settings are far more likely to return to those areas. Similarly, graduates from lower socioeconomic settings are more likely to provide care in underserved areas.7 Regionalized medical education offers opportunities both for recruiting and for motivating rural practice.
By coupling financial assistance with regional education, the impact of student debt and potential income on specialty and practice choice can be lessened. Community partnerships and community-based medicine provide alternatives to the medical training offered in urban, university settings. Educational experiences developed in regional centers are likely to permit training that crosses traditional disciplines and is more applicable to the practice opportunities in similar geographic areas. Finally, these regional programs will encourage students with rural roots to develop professional and social relationships outside the Portland metropolitan area during the formative years of medical school, thus further imprinting the value of nonurban practice.
Regional Medical Education and Its Impact on Physician Distribution
The OHSU AHEC program is a key component in addressing physician distribution and rural care issues. Recent admission trends establish that approximately 30% to 50% of OHSU medical students come from outside the state, and an increasingly smaller percentage of all matriculants have a rural background. The AHEC program has provided all OHSU SOM students with a required third-year, community-based primary care clinical experience in a rural area and has supported the family medicine residency rural training program.
Regional campuses will intermesh with Oregon's AHEC system as well as the state's higher education system. For example, Corvallis is an AHEC site as well as home of Oregon State University. In February 2007, with the governor, the CEO of Corvallis's largest health system (Samaritan Health Services), and much media in attendance, the presidents of OHSU and Oregon State signed a memorandum of agreement to establish a regional campus of the OHSU SOM at Oregon State University.
Much of Oregon is medically underserved, as evidenced by the 2005 census of active and practicing physicians in Oregon by geographic region and per 100,000 population. Compared with 311 physicians per 100,000 population in the Portland metropolitan area, Eastern Oregon has only 147 physicians per 100,000. To increase the number of rural providers, the AHEC program is expanding its delivery of rural education programs to include the Oregon Rural Scholars Program. This program has three core elements: to identify, recruit, admit, and provide financial assistance to medical school applicants who demonstrate interest in and aptitude for rural practice; to provide an enriched, rural-centered curriculum; and to provide retention support and professional development for practicing rural physicians.
The regional campus system, AHEC, and community-partnerships with area health systems offer a strong matrix for building a statewide, collaborative medical education program addressing physician workforce and distribution issues. Given that approximately 50% to 60% of graduates of OHSU SOM or an OHSU residency or fellowship program practice in Oregon, the SOM must be the catalyst for changing distribution patterns.
Improving Physician Distribution
The question of how to ensure distribution and placement of physicians in rural practices is in part answered through community-based regional medical education. Regional campuses, AHEC, and the Rural Scholars Program all provide early exposure (before the student commits to a specialty) to the rural practice experience. In addition, greater rural health funding is imperative to achieving adequate physician distribution Community support for rural physicians, including loan forgiveness and loan adoption programs, should be implemented and encouraged. Scholarships specific to rural health service—and not limited to primary care disciplines—must be readily available if an adequate rural physician workforce is to be achieved.
Medical students training in rural sites, financial incentives for rural practices, and support for rural health care are more easily addressed than some of the cultural issues that often drive physicians back to urban environments. Educational opportunities for physicians' children and accommodating the cultural and professional interests of physicians' spouses create more challenging obstacles to overcome. In addition, physicians from or educated in urban settings are accustomed to a more extensive social matrix than is often available in rural settings. Nonetheless, there is evidence that attracting and educating a diverse student population, including students of rural heritage, and providing training experiences in nonurban settings are helpful strategies for developing a physician workforce for underserved areas. Early career counseling (including debt-management counseling) during the premedical education, and actively cultivating medicine as an achievable option for underrepresented groups, are also essential in addressing physician maldistribution issues.
Meeting Needs and Achieving Goals
OHSU has a public obligation to meet Oregon's needs for an adequate supply of health care providers and to conduct a progressive, viable business sustaining its educational programs in a competitive marketplace. Regional campuses developed in conjunction with state universities and with private health care systems will help fulfill OHSU's mission to educate quality physicians, create a collaborative that is mutually beneficial to all partners, and strengthen the dozens of coordinated health care outreach programs serving residents throughout Oregon.
Implementation of the Oregon model for expansion is still in progress. To date, the regional campus developed in Eugene with the University of Oregon and PeaceHealth, with Sacred Heart Medical Center and PeaceHealth Medical Group clinics, has been reproducible in Corvallis with Oregon State University and Samaritan Health Services. The greatest challenge the OHSU SOM has faced in its regionalization efforts is securing necessary funding from the state legislature, despite the support of the Oregon governor. The program remains, however, on target and on budget.
A model for expansion to ensure an adequate physician workforce should be strategically developed to maintain educational quality and to contain any additional demand on limited resources. Given the short time frame to confront the projected physician shortage, the expediency of expansion can be enhanced through community partnerships. Establishing regionalized medical education in nonurban areas and matriculating the student population best suited for the physician workforce of the future are key elements of the Oregon physician workforce expansion model.