Mission statements are important contemporary tools of organizational identity and management and have become ubiquitous among nonprofits and institutions of higher education, often required by accreditation agencies and donors. Empirical evidence shows that the mission statement is a powerful tool of change and is associated with higher employee motivation and organizational performance.1 Colleges and universities are particularly proactive with their mission statements—a study done by the American Association of Colleges found that 80% of all colleges and universities were actively making major revisions to their mission statements, goals, and curricula.2 Mission statements for most U.S. MD- and DO-granting institutions can be found on their Web sites. The ubiquity and influence of mission statements make them ideal starting points for an examination of the self-defined purpose of U.S. medical schools and their roles in addressing the nation’s health care challenges.
U.S. medical schools have distinguished themselves in basic and clinical research and in providing cutting-edge clinical services. Yet the most basic role of medical schools remains the education of the nation’s future physicians—a responsibility that only medical schools can carry out. In recent years, as emerging problems with access, quality, and cost have come to dominate the nation’s health care agenda, many have urged a new responsiveness in U.S. medical education. The issues of social justice and social accountability in medical education have come to the forefront recently.3 Chronic physician shortages in rural and poor communities have raised questions about the role of medical schools in training students to address the needs of rural and underserved populations.4 The addition of 30 million people to the ranks of the insured as well as the continued aging of the population will put enormous pressure on the primary care workforce in the future. These realities have led to renewed calls to orient medical education toward primary care and the prevention of chronic and infectious diseases.5
The inordinate cost of medical care in the United States has raised questions about the training of physicians in the areas of cost management and the prudent use of medical resources.6 A number of groups have issued proposals to diversify the physician workforce—to educate more racial/ethnic minorities and individuals from economically disadvantaged backgrounds—to better mirror the diverse backgrounds of American patients.6
The purpose of this study was to quantify the relative prevalence of traditional and emerging themes in medical school mission statements. The traditional themes tracked in this study are education, research, and service. The emerging themes represent aspects of medical education that many agree are necessary for the development of a physician workforce able to address the current challenges facing the U.S. health care system, including prevention, embracing the prevention of both chronic and infectious diseases; diversity, including ethnic, cultural, socioeconomic, and geographical diversity of the student body; primary care, comprising education and training for generalist practice; distribution, referencing the importance of physician practice in rural and urban underserved areas; and cost control, prioritizing cost consciousness and cost-effectiveness in clinical practice.
The study also compared mission statements between different groupings of medical schools: MD-granting versus DO-granting, public versus private, community-based versus non-community-based, by level of National Institutes of Health (NIH) funding, and by date of initial accreditation (before or during/after 2000).
In 2011, we obtained the mission statements of 136 MD-granting U.S. medical schools from the 2010–2011 Medical School Admission Record (MSAR), provided by the Association of American Medical Colleges (AAMC).7 We also obtained the mission statements of 34 DO-granting U.S. medical schools from the American Association of Colleges of Osteopathic Medicine (AACOM) Web site.8 Inclusion criteria were initial accreditation and enrollment of students prior to November 2011. We used NVivo qualitative analysis software (QSR International, Doncaster, Victoria, Australia) to analyze all mission statements. Two investigators independently reviewed each mission statement, reading for content consistent with the three traditional themes (education, research, service) and the five emerging themes (prevention, diversity, primary care, distribution, cost control). We identified the traditional themes on the basis of a literature review and selected the emerging themes on the basis of calls to action in the published and gray literature from academics, the government, and professional associations. We selected emerging themes that appeared repeatedly in this literature review and were prominent in medical education fora. We used deductive qualitative analysis during the review, with no new additions to our preidentified themes (see Table 1 for a sample of the key words and phrases and their associated themes). Individual phrases could be labeled with multiple themes, so inclusion in one category did not preclude labeling in another category as well. We reconciled all differences to produce a single data set.
We categorized the medical schools by MD-granting/DO-granting, public/private, timing of initial accreditation, community-based/non-community-based, and level of NIH funding. We selected these categories on the basis of their potential for informing policy around the expansion of medical education and to understand which type(s) of schools may offer a strategic advantage in meeting the health care needs of the nation. We divided schools evenly into two groups (top and bottom tier) by level of NIH funding.9 We also classified schools by year of accreditation based on initial accreditation (before 2000 versus during/after 2000), as indicated by representatives from the Liaison Committee on Medical Education and AACOM.10,11 The AAMC designates community-based medical schools to acknowledge those that have emerged around the “community-based” movement in medical education and that use community hospitals to achieve their educational mission. To designate medical schools as public or private, we started with their entry in the MSAR, then updated the list as necessary. We used chi-square testing to statistically analyze differences in the prevalence of traditional and emerging themes between evaluation categories.
Traditional medical school activities were prominent in the mission statements that we analyzed. Education was present in the mission statements of all 170 U.S. medical schools, while research was referenced in 146 mission statements (86%) and service in 150 (88%). New and emerging themes were found with far less regularity, with 41 schools (24%) referencing distribution, 32 (19%) primary care, 27 (16%) diversity, 9 (5%) prevention, and only 2 (1%) cost control (see Table 2).
Primary care and distribution were mentioned more often in the mission statements of DO-granting, newer, community-based, and bottom-tier NIH schools than in the mission statements of MD-granting, older, non-community-based, and top-tier NIH schools, respectively. The difference between DO-granting and MD-granting schools was statistically significant (P < .05; 13 [38%] versus 19 [14%] for primary care; 15 [44%] versus 26 [19%] for distribution), as was the difference between community-based and non-community-based schools (22 [39%] versus 10 [9%] for primary care; 24 [43%] versus 17 [15%] for distribution) and NIH bottom versus top tier (23 [27%] versus 9 [10%] for primary care; 29 [35%] versus 12 [14%] for distribution). Somewhat surprisingly, we found little difference in the frequency with which private schools and public schools mentioned primary care and distribution (15 [19%] versus 17 [18%] for primary care; 19 [25%] versus 22 [24%] for distribution), while newer schools mentioned primary care and distribution more than older schools (7 [25%] versus 25 [18%] for primary care; 9 [32%] versus 32 [23%] for distribution).
Diversity was mentioned more often in the mission statements of MD-granting and older schools when compared with DO-granting and newer schools (23 [17%] versus 4 [12%] for MD-granting/DO-granting; 24 [17%] versus 3 [11%] for old versus new). We found virtually no difference in the frequency of mentions of diversity between all other categories of schools (public versus private, community-based versus non-community-based, and NIH bottom versus top tier), with all clustered at about 16%. Prevention (9 schools) and cost control (2 schools) were rarely mentioned.
The principal technical limitation of this study was how up-to-date the mission statements were, most of which we obtained from the MSAR and school Web sites. We had no way of knowing when these statements were written or if they have been superseded by more recent strategic planning activity at the schools. The principal policy limitation was our assumption that medical schools are making decisions and instituting policies in accordance with their mission statements.
Our analysis of mission statements provided an opportunity to compare the self-described aspirations of U.S. medical schools. Research was mentioned by 86% of medical schools and was a prominent element for all categories of schools. The majority of medical schools prioritized research despite the wide range of research funding and activities across the spectrum of schools. Of note is that the category with the highest percentage of schools citing research in their mission statements was DO-granting institutions (91%), despite generally modest research programs. This finding suggests that research may well be an aspirational value among medical educators even if it is not the current reality.
A more distinctive pattern of variation appeared in our analysis of the presence of emerging themes in mission statements. The DO-granting, newer, community-based, and bottom-tier NIH-funded schools all prioritized primary care and distribution more often than the MD-granting, older, non-community-based, and top-tier NIH-funded schools. We were not surprised by these findings given the history of these schools. DO medicine as a discipline is characterized by its rural origins and emphasis on primary care and by its recent efforts to open new schools in rural and underserved areas, such as the University of Pikeville in Pikeville, Kentucky, and Touro College of Osteopathic Medicine in Harlem, New York. In addition, many community-based medical schools were started in response to the local need for physicians, which explains the prominence of workforce priorities in their mission statements. The prominence of primary care and distribution in the mission statements of schools with less NIH funding may reflect that these institutions are less engaged in research and hospital medicine and more focused on educational priorities and addressing regional needs.
Although these observations may conform to conventional wisdom that more prestigious schools are less “community oriented,” the implications for medical education and workforce development are problematic. Graduating sufficient primary care physicians to provide reasonable and affordable access to care in all communities will be critical in realizing the benefits of the Affordable Care Act.
The least frequently cited themes were prevention and cost control. From a policy perspective, the importance of prevention in health care and the threat that continuously escalating costs pose to the country have been prominent national concerns for more than three decades. Our analysis would suggest that these issues have not been embraced by medical schools as priorities for organizational commitment.
From a health policy perspective, these findings raise a number of important issues. If emerging themes are not part of a school’s mission statement, it would seem unlikely that they will be given prominence in the program and will be a product of the school. Including emerging themes in the mission statement certainly does not guarantee translation into tangible results, but omitting them suggests that the school has not embraced these issues, which are national priority concerns. As schools do periodic strategic planning, there is ample opportunity for them to rethink and redraft their mission statements to put more emphasis on the emerging physician needs in the community and the country. This evolution of purpose would align the educational programs of many well-known and well-regarded institutions with the need for a well-distributed, primary-care-based workforce to achieve quality and affordable care for the population as a whole. Doing so would not require those institutions to forgo their commitment to research or excellence in advanced clinical care. Diversity of purpose is and should remain a characteristic of U.S. medical education. Without the active engagement of many established medical schools, however, the national health care problems represented by the emerging themes we studied—prevention, diversity, primary care, distribution, and cost control—will not receive the attention they need.
Acknowledgments: The authors wish to thank Dr. Henry Sondheimer for his help with the formation of this study and Dr. Samuel Simmens for his guidance with the data analysis.
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