Watson, Robert T. MD
In 2003, I published an article in Academic Medicine, “Rediscovering the Medical School,”1 which opened:
For several decades now, members of the academic medicine community have recognized that as the size of faculties has increased, participation in the education of medical students has become a marginal activity for a large percentage of the medical school faculty. In more recent years, faculty who have been involved in educational activities on a regular basis, on occasion, found it more difficult to participate in those activities because their salaries are derived increasingly from self-generated funds.2
Medical schools that are part of academic health centers (AHCs) are vital for caring for needy patients, creating new knowledge, educating residents and other health care professionals, and serving as economic engines for their communities and states. While accomplishing these missions, largely through building clinical and research enterprises, medical schools have also made many improvements in the education of medical students. Despite these education advances, the other significant and vital missions of modern AHCs have increasingly moved the education of medical students to the periphery in many medical schools. In 1996, David Korn3 wrote that “medical schools need medical students, not so much to teach them but to give the entire apparatus of the school a justification for being.” That observation was timely and prescient.
Why Medical Student Education Has Been Marginalized
In my 2003 article, I proposed several reasons why medical student education had moved to the periphery of the missions of traditional medical schools that are part of larger AHCs. Research had become the dominant academic mission. The importance of research for promotion and tenure and the growth in the number of basic science faculty had no direct relationship to the learning needs of medical students. This problem was underscored by scientists often working in centers or institutes without a direct relationship to a discipline-specific department.
Beginning with the enactment in 1965 of Medicare and Medicaid, the number of clinical faculty had increased dramatically, reaching 86,000 faculty by 2003. The number of residents in programs accredited by the Accreditation Council for Graduate Medical Education almost trebled in 25 years, reaching around 100,000 for all residency years, and including osteopathic and international medical graduates. This growth occurred during a time when there was no increase in the number of U.S. MD student graduates, which remained around 16,000. Despite this growing faculty-to-student ratio, the demands for increasing clinical productivity and funded research made it ever more difficult for many faculty to find time to teach. The organization of clinical activities in faculty group practices blurred some historically discipline-based activities, including the education of medical students. Medical schools had become federated systems, semiautonomous units controlling their own resources. Although this organizational structure was favorable to their growth and development, it fostered reductionist research and increasing clinical specialization. Medical student education did not control its own resources, and increasing specialization was not favorable to the general professional education of medical students.
I proposed possible new directions that might allow rediscovery of the medical school in an AHC because awarding the MD degree remains a medical school’s only unique mission. These included calls to
* adopt mission-based management,
* use mission-based budgeting,
* create a national task force to consider an optimal organizational structure,
* have a core teaching faculty educate medical students,
* establish a matrix salary structure for faculty,
* implement a possible solution to fulfilling medical schools’ social mission, and
* focus a specific part of the organizational structure of medical schools on medical students’ education.
The above proposals were perhaps too impractical at the time because they called for changes in an enterprise that had been successful for decades. It had become difficult to think in terms other than growth, and that growth would always attract revenues. However, I believe that since 2003, changes have occurred that make clear that we must think in terms other than growth because current structure and financing of medical schools may not be sustainable.
An Impending Catastrophe for Some Medical Schools
In 1798, Thomas Malthus4 proposed what is now sometimes called the Malthusian catastrophe. His observation was that because the growth of the population was exponential while the production of food was linear, a time would come when the size of the population would exceed its capacity to produce sufficient food for its needs. (This didn’t come to pass for all countries for various reasons, the main one probably being the Industrial Revolution.)
Traditional medical schools may be on the path toward their own kind of Malthusian catastrophe. In the past, they experienced remarkable growth that, for a time, was supported by an exponential increase in resources, largely from the public funding of research and revenues from providing clinical care. In response to the National Institute of Health’s doubling of research funding over the five-year period from 1999 to 2004, medical schools constructed large research facilities and hired many additional scientists.
This exponential growth in research funding has now ceased. Clinical facilities were built or purchased, and clinical faculty added to increase the generation of clinical revenue, but reimbursement for clinical care is now decreasing. Clinical faculty must continuously increase their clinical efforts, which becomes more and more difficult, to offset decreasing unit reimbursement. Clinical centers also heavily invested in clinical activities—generally procedural ones—that were more likely to generate revenue. This further fueled specialization and compromised the environment for the provision of a general professional education for medical students.
The costs of health care have continued to increase, resulting in the projected expenditures from Medicare being unsustainable and the costs of Medicaid overwhelming state budgets. The Balanced Budget Act of 1997 capped Medicare support of residents at the number of residents funded in 1996, and residents’ working hours have been restricted. Faculty members and residents have even less time to teach medical students. Just as in the research mission, the growth of the clinical enterprise may be in danger of exceeding its sources of revenue. Although efforts are ongoing to make health care more efficient and cost-effective, to find other sources of support for research, such as from industry and philanthropy, and to protect the public’s contribution to education, these may be in danger of being insufficient to support the large enterprises that now exist.
One School’s Different Approach to Medical Student Education
Twelve years ago, the first new MD-granting U.S. medical school in 25 years was created—the Florida State University College of Medicine (FSU COM).5,6 This medical school was explicitly founded on the concept that its core and major mission would be the same: the education of medical students, especially students who were interested in primary care. Faculty members were hired specifically to teach, and a general professional education to prepare graduates to become exemplary residents was the guide to curriculum development, management, and evaluation. The regional campuses model, where medical students learn one-on-one with practicing physician preceptors, was different from that of traditional medical schools with geographically distant campuses or having some clinical education opportunities in communities.
The founding of FSU COM occurred before I joined the faculty. As it was being established as a medical school and in its early years, I was among its most vocal doubters and critics. But actually working at this new medical school has convinced me that a different kind of medical school can be highly effective in the formation of future physicians.
It is perhaps more important than ever to protect and preserve our traditional medical schools while at the same time creating ones where clinical learning is fostered by practicing community physicians. The FSU COM has six regional campuses where, during their third and fourth years of medical school, 20 students from each class of 120 students learn clinical medicine. Each regional campus has a full-time dean and beautiful facilities. The FSU COM students gain about 70% of their clinical experiences in ambulatory settings during the third and fourth years. Students learn with their physician preceptors in both office and hospital settings. Students’ experiences with residents on any service at any location are minimal. Creating a robust faculty development program is required for the success of this model. An organizational structure and monitoring system to ensure comparable learning experiences for all students at all campuses is essential.
The outcomes of FSU COM’s model have confirmed its value. It is not only the first new MD-granting U.S. medical school of the 21st century but also the first such school in the 21st century to undergo the continuation-of-accreditation process of the Liaison Committee on Medical Education, which occurred in 2010–2011; it received a full eight-year continuation of accreditation. There were no areas of partial or substantial noncompliance on either the educational program for the MD degree or medical student standards. Since the time that its first class completed medical school, FSU COM students have averaged 17 points higher on the United States Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) exam than on the Step 1 exam. The Class of 2012 had a 100% pass rate for first-time takers on USMLE Step 2 CK and Clinical Skills exams. The 2011 Association of American Medical Colleges Graduation Questionnaire results7 are a strong indication that FSU COM students believe they are receiving an excellent education. In response to “Overall, I am satisfied with the quality of my medical education,” 96.3% of the FSU COM responders marked “agree” or “strongly agree” compared with 88.9% of responders at all schools.* The FSU COM students have done exceptionally well in matching to residency programs of their choice.
A Model for Training Primary Care Physicians
The FSU COM was established at a time of great skepticism about the need for more physicians in the United States, the school’s proposed model of community-based education, and the effectiveness of practicing community preceptors. The FSU COM has been a great success. There are many factors contributing to this success, but development of a new model without the constraining traditions that exist in established medical schools that are part of AHCs may be the most important factor. The outcomes provide evidence that this model of medical student education is not less effective or “second class” to the education of medical students at traditional schools within AHCs.
This model might be an effective way to create increasingly needed community-based GME primary care positions, including positions in general surgery and obstetrics–gynecology. These GME programs would be located in established regional campus communities, and the appropriate board-certified community practicing physicians would help the residents learn. The central campus would be the sponsoring institution for these distributed consortia of GME programs. Funding for these programs would come from a combination of federal, state, and community resources that would be determined by state and local physician workforce needs. The residents, supported in part by the state and local community, would be required to repay part of the funds they received if they subsequently decide to subspecialize. Creating community-based primary care GME positions would produce more primary care physicians than would creating more primary care GME positions in traditional medical schools because residents in the traditional programs would be more likely to subspecialize.
Perhaps existing AHCs should rethink their strategies in order to be able to continue advancing medical research, patient care, and health professionals’ education. These AHCs could be the center of a health care system that would depend on them for direction, for discoveries, as “safety nets,” and as recipients of the most difficult patient referrals. The focus for their medical student education mission could be on educating MD/PhD students, future leaders of science and patient care, or any of the other specialized tracks being created in some schools. They would also continue to educate non-primary-care residents and fellows. I am not implying that medical students graduating from a traditional AHC-based medical school can’t become outstanding clinical practitioners or that students attending a distributed regional campus medical school can’t become outstanding clinical scientists, leaders, or subspecialists. In the approach I envision, there would be no “first class” or “second class” institutions but, rather, a coherent and coordinated system of education, patient care, and research to provide the best health care to all.
Acknowledgments: The author wishes to thank Nancy Hayes, PhD, and Gregory Turner, EdD, MBA, MPH, for their suggestions and editorial assistance. The data from the 2011 AAMC Medical School Graduation Questionnaire Individual School Report: Florida State University College of Medicine and from the 2012 AAMC Medical School Graduation Questionnaire Individual School Report: Florida State University College of Medicine were used with permission of the Association of American Medical Colleges.
Other disclosures: None.
Ethical approval: Not applicable.
* The percentage of FSU COM graduates responding to this question was 56%, whereas the percentage of all U.S. graduates responding to the same question was 77%. Nevertheless, I think that the responses of the FSU COM graduates were representative of the views of most FSU COM graduates, especially because the percentages of graduates responding “agree/strongly agree” to the same question on the 2012 Graduation Questionnaire compare similarly (97.1% for the FSU COM students, 89.2% for all students).8 Cited Here...