With the new millennium came a second great expansion of U.S. medical education,1 but this time without the federal funding that supported the first great expansion during the 1960s.2 For many of the community-based medical schools founded in the 1960s, as well as many state-funded medical schools, the new millennium has been a time of increasing costs and declining resources to support education and research. In 2004, the challenges faced by the Michigan State University (MSU) College of Human Medicine (CHM) were met with opportunity, when college and university leadership were approached by community leaders in Grand Rapids, Michigan, about moving the medical school to their community, the second-largest city in Michigan and one of the few cities in the state with a growing economic and population base. The opportunities for partnership and for additional research, education, and philanthropy resources were considerable. The challenge inherent in the opportunity was to bring value to the partners and achieve the advantages of partnership without losing the historical vision of CHM.
Planning for these anticipated changes required thoughtful reflection and creative problem solving, not to mention efforts at presaging the future. Now, having progressed through the planning and successful implementation of an expansion, we reflect on what it means to be a community-based medical school and how this has evolved over time in response to the changing health care needs of the population. We also describe the growing pains and lessons learned from the largest and most rapid expansion of a U.S. medical school to date.
A Model for Community-Based Medical Education
The first great expansion of medical education in United States was during the 1960s. The tremendous growth in postsecondary education also resulted in an almost 50% increase in the number of accredited medical schools and a doubling of medical school graduates into the workforce.1 A number of community-based medical schools were established during this time; CHM at MSU was among the first, admitting its inaugural class of 26 students in 1966.
The founding vision of CHM, to educate the students of Michigan in the communities of Michigan in order to practice in the state of Michigan, fit naturally with the MSU land grant philosophy. This model also was supported by the state legislature, the university community, and the existing medical schools in the state, which had initially promised opposition to a new medical college.3 A mission statement approved by CHM faculty early in its history stated, “The primary mission of the College is the education of physicians who will bring the most sophisticated scientific knowledge to bear on medical problems and health status … who will take strong leadership in bringing about social change that will ensure equal opportunities for health for all individuals in their communities, states, and the nation…. A corollary of this mission has been to focus on the education of primary care physicians.”4 CHM focused on innovative approaches in the education of primary care physicians, thereby creating a distinctive model and culture for the medical school. The legislative directive implied that CHM would need to admit a broader range of students than had traditionally been accepted to medical school, creating a diverse workforce that could respond to the needs of the increasingly diverse population in Michigan.
It is noteworthy that around this time negotiations began for establishing an osteopathic medical school; in 1970, the College of Osteopathic Medicine (COM) was established at MSU,5 becoming the first osteopathic school affiliated with a major university. The legislature intended that the two medical schools would share resources and cooperate in the education of medical students.5 Since that time, the two schools have shared teaching space, educational resources, and faculty, and first-year medical students in both colleges have taken their basic science courses together. Though the organizational structures differ, both colleges use a community-based approach to clinical training. The presence of two medical schools makes MSU unique; together, the two medical schools matriculate over 500 students per year. The COM has also been undergoing expansion, adding campuses in southeastern Michigan. Though related, the stories of these two medical schools remain quite distinct; for this reason, this article focuses on CHM.
The Impetus for Expansion
By many measures, both the institutional model and culture of CHM have been successful. Consistent with the founding mission, CHM has graduated a higher percentage of women into medical practice6 compared with medical schools nationally. As of 2009, CHM also ranks above the 80th percentile among U.S. medical schools for the proportion of black and Hispanic graduates,7 above the 80th percentile for graduates practicing in rural areas,7 and above the 90th percentile for National Health Service Corps participation.8 Nationally, 37% of our graduates practice in locations designated as health professions shortage areas,9 and approximately half of graduates (48%) practice in primary care specialties, again placing CHM above the 90th percentile nationally.7 Since the founding of CHM, the proportion of graduates remaining in-state has increased from 39% during the 1970s to more than 50% in recent years, such that CHM is at the 60th percentile relative to other medical schools.7 Ultimately, approximately half of CHM graduates remain in Michigan, many of them in what are traditionally underserved and rural communities.
Despite these successes, the economic context and scholarly environment have changed dramatically since CHM’s founding. Research and clinical programs were originally designed to support the educational program rather than flourish in their own right; this has, in reality, limited the potential for growth. The reliance of community-based medical schools on relatively small population centers for education limits the scope and opportunity of both clinical and research programs. The state legislature has consistently and significantly reduced financial support to the university, which in turn has pushed CHM and faculty toward more clinical activity and an increasing emphasis on funded research. Meanwhile, clinical revenue from a primary-care-dominated faculty has not kept up with the costs of maintaining and reinvesting in educational programs. In many ways, the vision that made CHM so distinctive in 1966 has increasingly restricted its ability to weather economic difficulties almost 50 years later, challenging its long-term viability.
The expansion has also focused serious reflection on what it means to be community based. In truth, CHM had not brought the full benefits of academic medicine to its communities, which was part of the founding mission to which it had aspired. Although the community medical education programs were strong, little research or clinical innovation was attribu table to CHM outside of MSU’s headquarters in East Lansing. The possibility of new partnerships in Grand Rapids presented the opportunity to make good on a strengthened university–community relationship. The proposal to move the medical school to Grand Rapids proved too attractive not to consider. In the early phases of discussion of moving the medical school to Grand Rapids, there was a change in leadership at both the college and university levels. In the meantime, faculty had organized to voice their concerns about the planned move. These events brought new perspectives to the table early in the process, providing for a broader discussion of issues.
After extensive discussions, the CHM and university leadership envisioned a strategy for expanding rather than moving the medical school. If the expansion proved successful, the medical school headquarters would be relocated in Grand Rapids while maintaining the funding and faculty resources of East Lansing. The change from moving the medical school to a more practical plan of expanding the medical school allowed rapid development of a four-year medical education experience in Grand Rapids, building on the successfully accredited existing base of faculty and administration, and privately funded through community partnerships. CHM could embrace its community-based history and mission and expand by partnering with the institutions in a robust community where a strong clinical education infrastructure had already been established.
The Growing Pains of Expansion
The two-phase expansion plan was announced in 2002. The first phase, in-place expansion of the campus in East Lansing, increased the class size by 50% from 106 to 156 students; the first expanded class was admitted in 2007. The second phase was the distributed expansion, with the initiation of a second four-year campus in Grand Rapids. With the 2010 opening of the Secchia Center for Medical Education in Grand Rapids and establishing the school headquarters in Grand Rapids, the class size was doubled, and 100 students now matriculate at each campus. Through this stepwise transition, a number of lessons have been learned.
Overcoming hidden agenda fears
Because the original plan had been for CHM to move from East Lansing to Grand Rapids, there was considerable anxiety and mistrust among students, faculty, the Lansing community, and the Grand Rapids community when the announcement was made that CHM would be expanding rather than moving. The initial fears of the clinicians in both communities centered on increased economic competition for patients; local residents feared the loss of their doctors and their medical care. Basic science faculty associated with the medical school feared the loss of the resources and collaboration inherent in the large, research-intensive university campus. Numerous “town hall” meetings, press releases, and information updates were required to address concerns and move forward to the planning stages for expansion. Students overall were less concerned about the location of their education—Some valued the opportunities and ambiance of a Big Ten campus in East Lansing, whereas others valued the urban medical center setting offered by Grand Rapids.
Maintenance of culture
CHM has been recognized as a leader with regard to the priority placed on the social mission of medicine.10 Students and faculty were most concerned about maintaining a culture that valued community service, respect for diversity, and community activism, all of which thrived at CHM before the expansion. It was not clear whether the distinctive features of the CHM culture would be sustainable across two 4-year campuses located 70 miles apart, much less a sense of a unified medical school class or unified faculty. A collective response among CHM leaders was to take steps to ensure that these values were sustained and that the students would have similar experiences in each preclinical community by embracing the principle of “one college at two sites.” An educational mission statement was created for the preclinical curriculum stating, in part, “To provide an educational environment that promotes respect and interconnectedness among faculty and students with the goal of promoting the values of CHM into the larger medical community.” This statement is shared with the medical students during their prematriculation orientation week and reinforced throughout the medical school experience. More recently, to foster the value of “patient-centered” medical care, CHM has rededicated itself to medical student-centered education.11 Another initiative was a proactive effort to track the success of our approach; an annual climate survey of all students was implemented to monitor student attitudes and concerns about their education during the expansion.
Policy development and professionalism
In the context of an increasing national interest in issues of professionalism, the process of expansion provided the opportunity to review and enhance CHM’s policies to provide consistent guidelines, diminish ambiguity, and ensure that students, faculty, and staff were clear about expectations. Some of the more salient topics include self-care, communication between students and faculty, timeliness, attendance and participation, conduct within examination settings, academic honesty/dishonesty, and behavior outside of medical school.
Recruitment and hiring
Administrators and faculty for Grand Rapids were selected with priority given to those who value the CHM mission. Prospective candidates learned about the historical CHM mission and met with students who effectively communicated the values of CHM with more openness than typical of faculty. In addition, we counted on the students to communicate the challenges that they saw in an equally frank manner. The process yielded a greater demand for teaching roles that could be met.
Technology and communication
The two-phase process of expansion also gave us ample opportunity to experiment with distance learning and videoconferencing. Success of the entire endeavor continues to depend on effective technology that supports educational innovation and distance learning between campuses. Detailed planning on many levels began well in advance of development of building plans. Faculty were required to adapt instruction for distance learning, and staff were required to become familiar with the basic operations of the equipment. Communication continues to be a major challenge of the expansion. Many meetings are now videoconferenced to two or more locations to support inclusion of faculty and students across our distributed campus system. During the initial years of the expansion, a technology team was formed; this team met weekly to support the intense communication and collaboration necessary to sustain effective operations at all times.
Standardization of the curriculum
The daily challenge of a distributed educational program is the delivery of a consistent educational program to all students in all locations. Historically, this was primarily the concern of the clerkships, with clinical education offered in multiple communities simultaneously. Although the curriculum is standardized for required clerkships at all locations, each community campus is encouraged to have complementary educational opportunities according to community needs. The opening of a second preclinical campus makes standardization a concern for all faculty. CHM has committed resources to distance learning through videoconferencing of lectures, increased use of hybrid instruction, and the development of more Web-based lectures and learning resources.12 Technology provides a number of opportunities to ensure standardization for all learners.
A Changing Landscape
Throughout the process of expansion, the implementation plan had to be modified to accommodate new developments over time. The doubling of the class size had implications for all of the community campuses where students received their clinical education. Clinical campuses had to find ways to accommodate a larger number of students by finding additional training sites or increasing the number of clerkship iterations.
As implementation of the in-place expansion was under way, three Michigan universities announced plans to open new privately funded medical schools. The first new medical school was announced in southeastern Michigan and had little direct impact on CHM. Elsewhere, a university in one of our clinical community sites announced the intention to open a medical school. This required CHM leadership to develop long-term transition plans for student education, anticipating the time when we can place students there. In another community, the hospital system became affiliated with a newly announced medical school, requiring a plan for relocating students to other sites to complete their clinical education. Our plans for augmenting clinical sites were modified, and recently two new communities presented us with opportunities in northern and mid-Michigan to further expand our commitment to rural medicine and to accommodate our increased and reconfigured professional training demands. Our expansion has allowed us to enhance educational opportunities in our existing community sites as well. Through enhanced regional partnerships, we are able to grow our regional campuses13 and increase the number of places available in our rural physician education program.14
The expansion of our Grand Rapids campus to a full four-year program has prompted other community campuses to consider options for growth. A recent gift by the Charles Stewart Mott Foundation in Flint will provide resources to increase the number of medical students receiving their education in Flint and facilitate the expansion of research and education in public health, as well as for CHM to consider innovative approaches to medical education building on local community needs.15
The Road Ahead
Although the CHM mission clearly reflects the community-based ethos of the founding generation, the economics of the last two decades have made it clear that CHM would have to broaden its scope to continue to thrive. Although it is a powerful approach to medical education, the community-based model has proved a challenge to the vitality of CHM. In addition, CHM has been unable to realize the full promise of academic medicine in its communities. To harness the potential of an integrated, community-focused academic model, expansion provided a critical opportunity for us to reinvent ourselves. Along with the expansion of the educational program, the system-wide expansion of the research and clinical enterprises is essential for stability and continued success. Never has it been so clear that the coming-of-age of community-based medical education is predicated on strong educational, research, and clinical service partnerships. The Grand Rapids community and numerous institutions in the region have partnered with MSU to build a medical education facility and a robust research portfolio. Careful research and educational expansion in Grand Rapids has promoted growth of educational programs throughout all seven communities where our students are educated. The goal remains the same: to bring the health, intellectual, and economic benefits of academic medicine to a vigorous region of the state.
As a medical school within a land grant university, CHM has an obligation to help Michigan communities by creating opportunity through health and education. Michigan will need an additional 4,000 to 6,000 physicians by 2020, particularly in rural areas.16 Our expanded numbers in our clinical training sites bring new programs and opportunities to these communities. In exchange, the institutions and people of our communities provide a compelling platform for learning, discovery, and dissemination of health care. As the Michigan economy changes from manufacturing to knowledge-based jobs, both education and health care provide long-term growth potential. And as the health sector grows in Michigan, the economic growth of our communities is enhanced through research funding and incubation of life-science-based business ventures.1
A recent study by Farnsworth and colleagues2 reported that almost three-quarters of the newly accredited medical schools have adopted a community-based education model. This model capitalizes on the existing education and health care infrastructure necessary to support an approach to medical education that recognizes local health care needs, ultimately enhancing the vitality and sustainability of the partnership.17 Reexamining our commitment to community-based education has caused faculty to reflect on our mission and our future, resulting in a subtle but important shift in our mission. Although historically CHM has focused on the education of primary care physicians, the current decade has brought a new appreciation of the contemporary health care system and realignment to the health care needs of Michigan residents. Today, we talk about our social mission to “enhance our communities by providing outstanding primary and specialty care, promoting the dignity and inclusion of all people, and responding to the needs of the medically underserved.” This shift has freed faculty and students to consider a broader range of career options for themselves, and how the interface of these traditionally isolated avenues of health care is the point at which we can improve quality of life.
We are reinventing community-based medical education. We bring our founding values to focus on meeting local, state, and national needs. Expansion presented an opportunity to broaden and deepen our mission in otherwise-difficult economic times. As the expansion plans unfold, the focus now turns to research—not an area of strength typical to community-based medical schools. Having doubled its class size, CHM is working to build its research portfolio and is hiring funded investigators to substantially increase the university’s federal grant support and build intellectual capacity for the medical school and university. The expansion brings considerable attention and energy to all corners of the CHM campus system, and these new resources and vigor allow continued growth and innovation as a community-based medical school.
Other disclosures: None.
Ethical approval: Not applicable.
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