Wood, Douglas L. DO, PhD; Hahn, Marc B. DO
Accreditation of medical schools, both osteopathic and allopathic, serves several functions. Most important is the assurance to the public and prospective students that a medical school is meeting the accrediting organization’s stated requirements and criteria and that reasonable grounds exist for believing it will continue to meet them. Accreditation also provides a medical school an opportunity for critical self-analysis, which leads to improvement in quality. It also provides the school with consultation and advice from professionals from other organizations who have expertise in various aspects of accreditation. Ultimately, accreditation leads to public certification of acceptable institutional quality and an incentive for continuous improvement in the many components of a medical school.
In the United States, two agencies are recognized by the United States Department of Education to accredit medical schools, namely the Liaison Committee on Medical Education (LCME) for MD-granting schools and the Commission on Osteopathic College Accreditation (COCA) for DO-granting schools. Although each of these bodies consists of 17 members, in certain aspects their memberships differ. The LCME has six members appointed by the Association of American Medical Colleges (AAMC) and six appointed by the Council on Medical Education of the American Medical Association (AMA). Both the AAMC and the AMA each appoint one student member, and the LCME itself appoints the remainder of its public members. COCA consists of deans, educators, directors of medical education, and others, all of whom are appointed by the president of the American Osteopathic Association (AOA). A significant difference between the LCME and COCA is the absence of medical students on COCA. Without student input, an important voice relative to COCA’S accreditation decisions and discussions may be lacking.
Among some individuals and bodies there are questions when considering educational quality across allopathic and osteopathic medical schools. In some quarters, there are perceptions that the quality of education, and therefore the graduates of DO medical schools, are of a lower quality than is the case at MD schools. Although this issue could be explored from several fronts, in this article we examine the accreditation of DO and MD medical schools to attempt to determine whether differences in standards,1,2 composition of the decision-making bodies, and other issues could help account for real or perceived quality differences between the two types of medical schools.
Similarities and differences
There are similarities and differences in the basic structure of the accreditation documents across the two accrediting agencies. The LCME document begins with a segment titled “Institutional Setting,” which contains two subheadings titled “Governance and Administration” and “Academic Environment.” The COCA document begins with “Mission, Goals, and Objectives” for the institution and then covers “Governance and Administration.” The largest component of the LCME standards is titled “Educational Program for the M.D. Degree,” which presents standards for educational objectives, program structure, teaching and evaluation, curriculum management, and evaluation of program effectiveness. The COCA document presents fundamentally the same standards; however, no segment on curriculum management is found. Both documents contain standards relative to medical students, faculty, and resources.
The structures of the COCA and LCME accreditation documents have many similarities. The major difference in the structure domain lies in the overview provided in the LCME document, as well as fairly lengthy explanation of the standards. The COCA document does not contain an overview per se, but it does have guidelines that explain the standards. We do not think that these small differences could lead to dramatic changes in educational quality.
Comparative analysis—individual standards
In this section, we examine and compare the LCME and COCA documents’ standards in five areas: governance and administration, academic environment, faculty, students, and educational program (curriculum).
Governance and administration
* The LCME’s relevant standard states that a medical school should be not-for-profit unless there are extraordinary and justifiable circumstances that preclude full compliance with the standard. COCA does not have this requirement.
* The LCME document requires a planning process that sets the direction for the medical school and results in measurable outcomes. Although the COCA document requires strategic planning, it seems to be specific for the educational program rather than the medical school as a whole.
* Both sets of standards require university or medical school documents that describe the organization of the medical school as well as the responsibilities and privileges of the administration, faculty, and students.
* Clear definition of authority and responsibility within the medical school is also required by both documents.
* The COCA document is more prescriptive about the qualifications of the chief academic officer (dean) than is the LCME document. The COCA requires the chief academic officer to “have the responsibility and authority for fiscal management of the COM” and to “be employed full-time by the COM.” The LCME document states that “the dean must be qualified by education and experience to provide leadership in medical education, scholarly activity, and care of patients.”
* Both documents require that the medical school have financial reserves and resources to achieve and sustain the educational program and to accomplish other institutional goals.
The issue of not-for-profit versus for-profit medical schools is one which is being debated throughout both the MD and DO worlds, especially in view of the recent provisional accreditation of a for-profit osteopathic medical school. How the for-profit business model will affect the quality of medical education in the United States has yet to be tested.
* The LCME document contains six standards under the title “Academic Environment.” These standards include requirements that (1) medical students should learn in clinical environments where graduate and continuing medical education programs are present, (2) the medical education program must be conducted in an environment that fosters intellectual challenge and a spirit of inquiry, and (3) the medical school should make available opportunities for medical students to participate in service-learning activities.
* The COCA standards make no mention of the academic environment or of such specific issues as intellectual challenge, spirit of inquiry, or student participation in service-learning activities.
The question raised here is, does the academic environment have a significant impact on educational offerings? This is a difficult question to answer from an empirical perspective because of the many confounding variables present. Most would conclude, however, that students learn better if exposed to environments where graduate medical education programs are present and where the environment fosters intellectual challenges and a spirit of research inquiry.
* Both LCME and COCA standards require that the medical school hire sufficiently and appropriately trained faculty in both the basic science and clinical areas to meet the needs of the school.
* The COCA standards strongly recommend that the medical school develop a faculty adequacy model appropriate to the school’s mission, objectives, and curriculum delivery model. The model is to be developed by each school, and therefore a different model might be used by each school. No standard model is provided. The LCME standards have no such requirement.
* Both sets of standards require a faculty development program.
Both sets of standards are so similar in this area that there are no unique quality implications.
* Both sets of standards require that admission policies and criteria must be developed.
* The COCA standards require that the school “tie its admissions process and criteria to the outcome performance of its graduates.” LCME standards have no such requirement.
* Both COCA and LCME standards contain guidelines for student selection.
* Both sets of standards outline requirements related to the acceptance of transfer students.
As in the comparison of standards regarding faculty, standards for students are very similar and do not have unique quality implications.
Educational program (curriculum)
Both COCA and the LCME have many standards in the area of curriculum.
* The COCA and LCME standards both require the development of educational objectives for the school’s educational program. In each case, the objectives are to be designed to serve as statements of what students are expected to learn or accomplish during the course of their medical education program.
* An outline of how the students should attain the educational objectives is included in both sets of standards.
* The COCA standards state that clinical core competencies should be attained by osteopathic students and suggest that, at a minimum, osteopathic students attain the seven core competencies that all AOA-accredited graduate medical education programs are required to foster (see List 1). (Six of the seven core competencies required by the AOA are similar to those required in MD programs accredited by the Accreditation Council for Graduate Medical Education.) Although implied in the LCME standards, there is no specific requirement in this area.
* Under the heading “Content,” the LCME standards are much more specific in what must be included in the curriculum than is the case in the COCA standards. For example, in the LCME standards, a statement is made that topics such as anatomy, biochemistry, genetics, and physiology must be included. Also, “instruction in the basic sciences should include laboratory or other practical opportunities, and instruction must cover all organ systems and include aspects of preventative, acute, chronic, continuing, rehabilitative, and end-of-life care.”
* The LCME standards are much more extensive in the areas of teaching and evaluation than are the COCA standards. The LCME standards also include several standards on curriculum management that are not found within the COCA standards.
* One area of significant difference between the two sets of standards lies in the prescriptive COCA requirement that all osteopathic students “must take and pass the National Board of Osteopathic Medical Examiner’s, Inc. (NBOME) Comprehensive Osteopathic Medical Licensing Examination COMLEX-USA, Level I, prior to graduation” (emphasis ours). The standard goes on to state that “students entering in the 2004-2005 academic year, and all students graduating after December 1, 2007, must pass the NBOME Level II Cognitive Evaluation (CE) and Performance Evaluation (PE) prior to graduation.” No such requirement relative to national board examination passage is found in the LCME standards.
The COCA document is explicit relative to core competencies; in contrast, LCME standards have no specific requirement relating to competencies. It is difficult to find medical education literature that presents solid evidence, either positive or negative, relative to the value of requiring these competencies.
The listing of specific curriculum topics in the LCME document, as opposed to none in the COCA document, might well provide more guidance to curriculum developers, but an unanswered question is, does this lead to enhanced educational quality?
The LCME standards are considerably more extensive in the areas of teaching and evaluation, as well as curriculum management, which could well lead to enhanced educational quality.
Whether passing the board examinations is evidence of educational quality is another area of debate. Also, is it the province of accrediting bodies to determine graduation requirements of medical schools? With our current level of knowledge, one cannot say with confidence that passing the board examinations can be equated with specific quality outcomes in education.
Summary and Comments
Each body (LCME and COCA) has the same number of members. However, those members are not appointed in the same way: The LCME members are appointed by three bodies, whereas COCA members are appointed by a single officer within an organization. Another significant difference is the lack of student representatives on the COCA compared with the LCME; thus, student representation is lacking within the COCA. It is difficult to determine whether these factors have any effect on educational quality or outcomes.
The basic structures of the LCME and the COCA documents are roughly equivalent.
The COCA standards do contain annotations; however, they are not found as frequently as in the LCME standards, nor are they as detailed as those present in the LCME standards. Thus, again, it seems that the COCA standards are more open to individual and/or group interpretation than are the LCME standards.
Appropriate interpretation of standards and consistency in such interpretation are essential components of accreditation. Improper interpretation could well lead to inadequate assessment of educational quality.
Governance and administration.
The major difference between the two groups’ standards is in governance. A for-profit osteopathic school has now been approved, while the relevant LCME standard states that a medical school should be not-for-profit unless there are extraordinary and justifiable circumstances that preclude full compliance with the standard. The question that arises is, does the LCME requirement lead to improved educational quality? As stated earlier, it is too early to have enough information to answer this question.
Standards in this area in the LCME document focus on student learning, as well as student participation in service-learning activities. The COCA standards are devoid of any mention of environment and mention student learning in only one standard (Standard 6.5). COCA also makes no mention of service-learning projects.
Student learning is the essence of medical education, and standards in this area should be essential. Student learning is a component of the assessment of educational quality.
There are similarities in this area between the two documents, yet at one point they diverge significantly. The LCME requires that medical schools have sufficient and appropriately trained faculty. The COCA strongly recommends that a faculty-adequacy model be developed by each school. No further guidance relative to the development of such a model is found.
The standards in this area are relatively similar in both documents except that COCA requires that the school “tie its admissions process and criteria to the outcome performance of its graduates.” There is no clear guidance as to how this is to be accomplished, given the many confounding variables that enter the picture between the admission and graduation of students.
Educational program (curriculum).
There are similarities and significant differences in this category of standards.
In the area of differences, the COCA standards state that clinical core competencies should be attained by osteopathic students and suggest that the seven core competencies required of all AOA-accredited postdoctoral programs be accomplished by medical students. The LCME has no specific standards of this type. Again, the value of such a requirement relative to positive educational outcomes must be considered.
Required curriculum content is much more specific in the LCME standards. But does such specificity lead to enhanced educational outcomes? Also, the LCME standards contain several requirements related to curriculum management not found in COCA standards.
The most significant difference in this area of the standards centers around the COCA requirement of passing the NBOME Level I and both components of Level II (Cognitive Evaluation and Performance Evaluation) prior to graduation. No similar requirement is found in the LCME standards. The logic behind such a requirement seems to be found in the statement that the osteopathic school must track performance of students on such exams “as part of a process to determine how well students accomplish the schools educational goals.” Does this mean that each school’s educational goals must be congruent with the NBOME line of questioning? Looking at this from another perspective, to be fair to students, the NBOME must be sensitive to construct an examination that adequately measures a student’s performance no matter which of the diverse osteopathic curricula formed the basis of that student’s education.
The issue of quality, and the standards in this area, were discussed earlier. The challenging questions to be answered are
* Does the requirement of core competencies by medical students influence educational quality?
* Does passing any of the board examinations indicate a high level of educational quality?
We began this article by stating that, in some quarters, osteopathic medical education is thought to be at a lower level of quality than allopathic medical education, potentially leading to a lower-quality graduate. The question we attempted to address then was, does accreditation across the two professions effectively evaluate this educational quality issue? Because of the reasons laced throughout the article, our answer is that, at the current state of the art of accreditation (as presented by both the LCME and the COCA), accreditation does not address this issue to the level where one can appropriately answer the question we posed.
Medical school accreditation is both an art and a science. Hopefully, as time goes along, it will become more of a science than an art as we determine appropriate metrics to identify quality attributes in medical school graduates. Both the COCA and the LCME continue to move forward in attempting to make sure that their respective medical schools have an acceptable level of quality and will continue to improve the many components of their higher education enterprise. The public, and current and future students, deserve nothing less.