Medical Schools: What Reforms Might Make a Difference

Nearly a century ago Abraham Flexner made his famous visits to medical school campuses across the nation. He had the support of a fledgling American Medical Association and the funding of the powerful Carnegie Foundation. His work was one of the most extensive studies of medical education ever done.

The Flexner report was perhaps the single effort that accomplished major change in a relatively brief period of time. The reports were widely circulated in articles in the dramatic style of the newspapers of the day. These reports, magnified by the media, resulted in the closure of several medical schools and many other changes.

The Flexnerian reforms clearly contributed to improvements in the quality of physicians. There were reductions in the number of medical schools with a resulting increase in demand for physicians. Perhaps one of the most important changes involved emphasis on better preparation of medical students before medical school. This change would have far-reaching impact. Those hoping to become physicians needed more rigorous courses and this stimulated major improvements in high school and colleges.

Flexner's favorite medical school model was one of the newest in the nation. Johns Hopkins became the model for medical education for the nation. Medicine, science, research, and hospitals became increasingly enmeshed, and the marriage seemed to be good for all, or so it seemed at the time.

There were other effects that became apparent over subsequent decades. Perhaps the most major impact was on the medical schools that were training physicians for the most challenging populations and locations. The Flexner reforms resulted in the closure of 3 of 5 medical schools graduating black physicians. Only Howard and Meharry remained. The reforms also terminated the traditional methods of training physicians for rural areas. Later changes in medical education away from generalism and toward preparation for subspecialties only made matters worse. The resulting maldistribution of health professionals has resulted in problems of health access for millions of Americans. Reservations, border towns, geographically isolated areas, and persistent poverty areas continue to suffer.

What Happened to the Education in Medical Education?

Various factors continue to move medical schools farther away from a primary emphasis on teaching as well as a societal need to graduate physicians that would go to underserved areas to improve health care access. Increasing emphasis on research has been stimulated by massive increases in National Institutes of Health funding. These funds can bring millions of dollars to medical schools. NIH grants are even more valuable as a source of funds since each grant pays as much as 50% extra to cover indirect costs, all to be used at the discretion of medical schools. In the mean time federal and state dollars directed toward the education of medical students have all but disappeared. Decades ago medical schools blackballed faculty who pursued individual research and patents that would result in personal gain. Now medical schools form business partnerships with all manner of corporations, "faculty," and interests. Research is not the only distraction from teaching and social need. Graduate medical education dollars are also major contributors to medical school finances. In recent years the growth of these funds has been curtailed. This leaves increasingly clinical revenues as a major source. Given the current reimbursement structure, it is a wonder medical schools graduate any primary care physicians who still plan to locate in underserved locations. Studies document the reductions in faculty teaching efforts. (see study) also Medical Education Retardation

It seems that history is being repeated. A series of reports and news articles has called the quality of medicine and medical education into question. The public attention has already been focused on this area as health care costs spiral out of control and physicians seem more and more distant from their patients. Reports from the Institute of Medicine note that medical errors kill tens of thousands each year. Concerns have been raised about resident work hours, the contribution of physicians training in other countries, and more recently about a possible shortage of physicians.

The focus of the month involves the two black medical schools that survived the Flexner reforms, Howard and Meharry. This particular media event involves studies using selected physician disciplinary data in an investigation by the Hartford Courant, the oldest newspaper in the nation. A series of articles raised questions. Controversy in Medical Education

It is not surprising that these schools are receiving attention. They have long faced challenges involving the preparation of their students, the lack of resources for training, and inordinate dependence on federal funding. Howard has also faced challenges regarding its graduate medical education programs. In recent years the top minority candidates have had their choice of any medical school in the nation. War chests fueled by alumni and medical school investments insure that many will bear few expenses. Local medical schools and schools such as Howard and Meharry do not have the same ability to pay students. The challenges facing such schools are reflected in the low Medical College Admissions Test scores of its students.

Howard and Meharry have been appropriately silent in response. It is a difficult and complex issue that deserves thought and attention. The medical school at Guadalahara Has Responded in an appropriate way. It is also a difficult area to study

It is interesting to view the controversy through the lens of medical education history. Cycles of controversy tend to consolidate the strong and challenge the weak, who either make the cut or succumb, with health access held hostage in the process. Lofty goals can get distracted in the process 3000 by 2000

Similar feedback loops exist for smaller colleges. Over the years medical and professional schools accept fewer and fewer from such schools. Even now studies demonstrate that the medical school failure rate for smaller, less traditional colleges is twice the rate of the usual sources (10.6% vs 5.3%) (Wheat et al JRH Small Colleges and Admissions). Parents of premedical students pressure college advisors for data regarding acceptance rates to medical schools. The pressure to succeed in this area is enormous. Smaller schools with less established reputations face the most difficult challenges.

Each round of state education cutbacks forces state college systems to make decisions. At the smaller schools, pre-professional education is expensive and involves few students. They are easy targets. In other words some schools were able to respond, others were left behind. Collections of data regularly reported by the media may contribute to a "rich get richer" type situation. Centralization and Regionalization

Suffice it to say that smaller schools, schools in rural areas, and schools dedicated to the education of minorities have had a difficult time attracting top candidates for professional school. They have also had a difficult time maintaining the challenging academic levels necessary to help graduates compete for professional school positions. After all, a major stimulus for excellence in higher education is the competitive nature of the students. Schools attracting top students will continue to stay sharp. Those with lower academic levels will remain behind.

In some instances partnerships between medical schools and such colleges have been able to reverse decades of decline in only a few years, restoring rural background medical students as well as the academic challenge. Such schools allow students to stay in rural areas for college instead of subjecting them to the urban lifestyles and spouses that may make it more challenging to return to rural areas upon graduation.

It is not surprising that those most likely to return to underserved areas came from such areas. Increasingly it is apparent that the admissions process of medical and other professional schools is perhaps the key area to restore leadership and jobs to underserved areas. Schools that do not attempt to chose the rural and minority students that will return to underserved locations are actually worsening the maldistribution of health, education, economic, and leadership resources.

However, if states refuse to invest in K-12 education in underserved areas, students from such locations will fight an uphill battle, not only academically, but financially and culturally. Indeed students arising from the lowest socioeconomic levels have declined precipitously in studies in Canada (Toronto). Those accepted to medical school with rural backgrounds in the US have declined from 28% to 16% in the past 20 years even though there has been no change in the rural-urban distribution of those taking the MCAT.

In Pennsylvania and Minnesota, states with some of the best educational achievements, efforts to select rural background students have resulted in outstanding outcomes. A program begun in 1971 involving a selective rural admissions track at urban, private Jefferson Medical School has graduated physicians that now comprise 21% of the rural family physicians in Pennsylvania. This program continues a stellar performance with only 1% of the graduating physicians of all 5 of the medical schools in the state. This program continues without state assistance. Duluth medical school continues to graduate more rural physicians than any other school. Despite incredible success, medical school accreditation has forced this school to merge with the University of Minnesota.

States or countries with less advanced education in underserved areas attempt to make up the difference in special preparation programs. In essence these programs attempt to continue the flow of minority and rural candidates, those left behind by maldistribution of education resources. The weakness of these programs, or indeed all specialized admissions, is that it is difficult to choose candidates that most desire to return to underserved areas. It is relatively easy to choose for academic or intellectual gifts. It is more difficult to choose from other characteristics that make candidates a better choice such as service motivation and ability to communicate. Another difficulty is that early contact can select out or socialize students toward research, subspecialties, or urban locations rather than service, primary care, or underserved locations.

The current selection process of Medical College Admission Test, grade point average, and interview also has weaknesses. It is easier for those with the right connections to take advantage of such programs. Students from urban schools or those with professional parents tend to know the ropes better. Rural candidates in particular seem to lack polish in their applications and interviews. It is also possible that the selection process rewards students for intellectual qualities while penalizing those motivated by service or involvement that can distract from academic performance. Students who must work during high school or college face many obstacles to a medical career.

Medical education itself faces some major challenges. Faculty are less involved with teaching with each passing year. Those who will practice medicine need to be able to make decisions on actual patients. Unfortunately this is becoming more difficult. Liability has taken decisions out of the hands of students and residents. Their teachers are less willing to take the risks. Also the "teaching" practitioners and attendings at hospitals no longer know their patients well. Modern health plans shuffle patients and physicians around like a deck of cards. Doctors who do not know their patients or who are seeing new patients are unlikely to let students and residents do much. Canadian medical students do not like coming to the US where they cannot practice on patients. In the few surviving rural preceptorships, students and residents rate their experiences as their best education. This is not so much a matter of the rural location as it is the fact that rural docs let students and residents do more. Medical Education Retardation

This is a study of medical schools, not physicians or particular medical schools!!!

Methods

Regression using national data on physician discipline rates by US medical schools as published by Hartford Courant. Note that only 8514 physicians were listed or only half of the physicians noted in the national database.

Hypothesis for the regression - Schools with more resources such as NIH grants and GME funds, schools with fewer minorities, and schools in states with higher science scores and greater education expenditures will have fewer graduates who are subject to disciplinary action. Schools in more urban locations and those with larger class sizes will also have more disciplinary actions.

Because some states are more active in disciplining physicians, the regression was weighted by ACTPop - a variable created by taking the number of actions of the state board of licensure in 2001 divided by the state population. This controls for variation in disciplinary activity in the state as well as for variations in active physician population. Some states may have far more physicians that are in training, young, or in retirement.

Independent variables

Disclaimer

The Courant noted that it could not match the physicians to their school in the remaining half. This is a bit concerning.

There is also a question whether the schools most commonly identified were identified at a higher rate. The regression model was not valid when including schools with the highest disciplinary rates. There could be problems at the medical schools noted in the reports but it remains that the selection process could have been responsible. Also the actions of the state licensure boards where many of the graduates located could impact the rates as well as graduates who are more mobile, with one disciplinary action causing reciprocal actions in other states and multiplying the number of actions for a particular school.

The data sets used are not chronologically equivalent with the physician dates in medical school. These data collections and verifications would take a more detailed study. The data used were mostly existing data collected by the author over a number of years in his study of medical schools and residency programs and rural graduation rates from the same. Unfortunately many of the data sets do not improve over time, as many in underserved areas continue to suffer and medical schools do little to graduate more for these areas.

Also it is difficult to see the contribution of state level data for the more national schools, although these schools do interact with state education and other areas.

Results

Several different regressions examined the variables and their impact upon the dependent NATPER or national percentage of physician discipline for the school.

Variables that contributed in the state or public medical school regression models

The initial regression runs noted a problem with outlier data for the most disciplined schools. Regression with all schools There was not a normal distribution of data with these schools. Since this was a regression directed toward identification of factors regarding disciplinary actions of medical schools in general, not specific schools, the skewed data was deleted.

Additional overlapping variables were identified. It is better to use just one measure of science, that of the BioScience MCAT score for the state. This was chosen over the 8th grade scores for the state as reported by Education Weekly. Equivalent results were obtained in regressions for either variable.

State schools operate differently than national medical schools. The following were divided to see if variables influenced the types of schools differently.

Regression with National- the model fit the national schools best with more variance explained and not much real difference in the contributing variables.

Effect of weighting for state disciplinary differences

States vary in their disciplinary actions. Schools with more graduates in those states would then appear more often in disciplinary data. This would of course vary by how much the graduates remained in state. The following regressions were weighted by the number of disciplinary actions against physicians in the state divided by the population of the state.

Regression All Weighted - best overall model fit of all schools except skewed schools, explains 40% of variance with class size (positive), change in ed expenditure of state location (positive), BioScience MCAT scores of state location (negative), and NIH amount of funding for school (negative).

Regression State Weighted - state schools discipline related to class size (positive), change in ed expenditure of state (positive), BioScience MCAT scores of state (negative)

Regression National Weighted - class size (positive), change in ed expenditure of state (positive), BioScience MCAT scores of state (negative)

Regression10 Older Schools - adds most urban location (Continuum Code of 0) to other variables resulting in more physician disciplinary actions for a medical school.

The last regression involves schools that responded to the US News graduate school survey. The data included MCAT scores by school, GPA, and Faculty-Student ratios. Use of this data in a regression of 72 schools resulted in a model that included the MCAT score of 2002 as significant. GPA and faculty-student ratios were not significant. Regression on US News schools who responded to their survey

Conclusions

Preliminary study and analysis Please!!!!! Be sure to read limitations and disclaimers.

The reasons for some medical schools to have more graduates disciplined than others is largely not able to be explained by this analysis or possibly any similar analysis. Medical school and state characteristics do seem to have some influence on disciplinary actions.

Medical schools with larger class sizes can graduate physicians who are more likely to have disciplinary encounters. This is not a surprise considering basic education principles.

Medical schools in states with inadequate preparations in sciences or with lower MCAT scores can graduate physicians who are more likely to have disciplinary encounters. Again not a surprise from past studies. Why this happens is of great interest.

Medical schools in states with greater increases in state education expenditures in the past decade had more graduates disciplined. This is a more complex variable that may relate to education, state investment in education, and state growth.

It is not possible to conclude that medical schools with a higher percentage of minority students are deficient.

Flexner himself felt that medical education could not improve without major improvements in the quality of the students who were to be selected. His years as a high school principal, educator, and researcher of colleges and medical school were not spent in vain.

A major concern of those hoping for better physicians is better distribution of education, especially science education. It follows that a major reason for areas with decreased access to health (and many other services) is the failure of education to prepare students from underserved areas to do well enough in K-12 and college to be ready for medical school. States with better distribution of educational resources such as Minnesota and Pennsylvania have been able to set up programs that have resulted in the graduation of physicians who not only go to small towns, but stay there many years in practice. This may also be true for inner city areas.

In the absence of a larger and more competitive array of students from rural areas or minority populations, it may be difficult to select those students that have the intellectual and personal characteristics that would allow them to do well enough to graduate, have the desired character to prevent future disciplinary problems, and yet still choose an underserved location.

Discussion

The best answer for reduction of disciplinary actions on a more global level is to improve K-12 education and use the leadership of medical and other professional schools to stimulate improved education at all levels.

Selected improvements such as smaller class sizes or methods to reduce the class size might have some impact. In recent years, medical schools have tended to integrate some amount of small group learning that may have some impact on the quality of physicians. These include small groups based on problem-based education, primary care initiatives, or physician communication training. Schools markedly reduce class size by graduating classes two or three times a year instead of once a year. They could also emphasize competency in such efforts as compared to passing exams. Students who failed a semester or quarter would not be penalized a whole year in expenses and debt. Also those who fell behind would not be so pressured to process material faster than they were capable, a risk factor for falling further behind in the future.

Government should carefully consider the problems with medical school resource allocation that may worsen distribution, making the "rich" schools richer and the poorer schools extinct, with unintended consequences regarding the distribution of health professionals and even worse health care access.

Different data on Graduate Medical Education funding might be more useful. Also NIH data is difficult to compare depending on the data resources. It is possible that both contribute more than is noted to either improving physician quality, or vice versa.

1. Are we willing to tolerate large populations of Americans with second class health care and education?

2. How do current federal and state policies influence medical education and the distribution of graduates?

3. Do we have methods of selection and training that can result in a better distribution of physicians and improved health access?

4. Do those methods result in the graduation of physicians with increased disciplinary problems?

5. Are these problems the responsibility of medical education, or do they reflect societal problems such as educational resource distribution?

· Enhancements in and partnerships with colleges with more diverse student populations that might result in a better distribution of physicians (rural, minority)

· Removal of the debt burdens of physicians which are a source of resentment that can last for decades and can result in problems for patients and programs and costs.

Medical Education Meets the Marketplace: What Mix of Tradition and Innovation Can We Afford? In October 1999, the New York Academy of Sciences organized a conference to examine the future of medical education and its financing. These are the full proceedings of that conference. http://www.nyas.org/books/medicaled/index.html