Letters to the Editor
We thank Dr. Bunton and Mr. Salsberg for their thoughtful comments about our article. We recognize that the decision to increase class size is an institutional decision and not a mandate from the AAMC. Nevertheless, we found it interesting that in a survey of deans prior to the AAMC’s recommendation to increase class size, the deans cited concerns about increasing class size that were nearly identical to those of the internal medicine clerkship directors.1 After the AAMC’s recommendation, more medical schools expanded their class size than would have been predicted and at a brisk rate, despite the cited concerns. In fact, our survey found that after the AAMC recommendation, the decision to increase class size was not a collaborative decision between the administration and faculty, at least at some schools. Thus, recommendations from the AAMC, a “strong force” in medical education, carry significant weight; to paraphrase an old ad campaign: “When the AAMC speaks, people listen—and act.”
We all agree that there is an obligation to conduct program evaluation to examine the impact of increasing class size on students, faculty, and society. Important curricular innovations precipitated by having to educate more students are important to share, although such last-minute innovations are reactive to external forces. The costs of educating more students in the clinical setting could be significant—it is not a simple matter to find and develop high-quality inpatient and ambulatory experiences, particularly when medical schools may be competing for scarce resources in the same area.
Finally, we must determine whether increasing class size fulfills its fundamental mission “to assure a sufficient supply of well-educated physicians to help assure future access to care.” The lack of an increase in GME training slots, a practice environment that pushes students away from primary care,2,3 and a prior history of poor prediction of physician supply should raise concern that we may or may not have enough physicians, or the right mix of geographical distribution of physicians, to meet our patients’ needs.
Paul A. Hemmer, MD, MPH
Vice chairman for educational programs, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland; (firstname.lastname@example.org).
Former executive vice president, Alliance for Academic Internal Medicine, Washington, DC.
Steven J. Durning, MD
Associate Professor of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
1 Cooper RA, Stoflet SJ, Wartman SA. Perceptions of medical school deans and state medical society executives about physician supply. JAMA. 2003;290:2992–2995.
2 Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300:1154–1164.
3 Bodenheimer T, Berenson RA, Rudolf P. The primary care–specialty income gap: Why it matters. Ann Intern Med. 2007;146:301–306.