The social mission of medical education: Admit different students

In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”,[1] June 17, 2017, Fitzhugh Mullan makes a convincing case for medical schools to be committed to their social mission. He takes his definition from the “Beyond Flexner” website (www.beyondflexner.org), which says “Social mission is about making health not only better but fairer—more just, reliable, and universal”. He details what this means in terms of commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, increasing diversity within the health professions. These serious issues have been identified for decades, but in fact the trend may be toward getting worse instead of better.

Mullan cites some examples of medical schools, primarily newer and “community based” schools, that are working toward these goals. These include Morehouse and Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982 respectively), those of a more recent expansion in the 2000s (Florida International University and the AT Still Mesa Campus), and those yet to come (the merger of Geisinger Health System and Commonwealth University, Kaiser Permanente School). But he also talks about “mainstreaming”, the need for consciousness about, and implementation of, social mission to be a characteristic of all medical schools.

I believe that the most important measures of a health professions school’s social mission are its outputs. Using the 3 criteria identified by Mullan and colleagues in their seminal 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”,[2] we need to look at whether its graduates are more diverse, whether they practice in underserved areas, and whether they are more likely to be in primary care specialties. The 2010 article showed that some schools do better -- more often those that are public, newer, and not in the Northeast -- but the fact is that none is doing all that well.

The number of students entering primary care is a critical indicator because, based on national and international comparisons, a well-functioning health system should have 40-50% of physicians should be in primary care; the US is well below 30% and going down. Family medicine match rates are the most sensitive indicators of primary care production, because unlike internal medicine virtually all family physicians practice primary care, so a choice of this specialty means a commitment to primary care. In addition, it is the specialty most suited for practice in rural areas. Even if all schools consistently produced 50% primary care physicians, it would take at least a generation to get to that number for all physicians in practice, and we are far, far from this.

In 2012 John Delzell and I looked at 10 years of data (2002-2011) published annually on the family medicine match by the American Academy of Family Physicians (AAFP) documenting the number and percent of students from each medical school entering family medicine.[3] We found only a few schools that were relatively high in both number and percent, with the University of Minnesota and the University of Kansas far ahead of the rest. And yet even those schools do not produce primary care physicians at the 50% rate. In the most recent AAFP report, on 2015 graduates,[4] even the “socially conscious” schools cited by Mullan did not have very high numbers matching in family medicine:  Morehouse 8 (12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the largest number in the nation, but still had 20 fewer than it did in 1999! In 1994, the Association of American Medical Colleges (AAMC) announced Project 3000 by 2000, aiming for 3000 minority medical students into US schools by the year 2000[5]. It failed. Today, in 2016-17, we are not only far from that number, but the percent of many minorities (especially African-American men) continues to drop.[6]

As in any process, the results of medical (and all health professions) education are affected by 3 sets of variables. Input variables are the students enrolled, process variables include the curriculum and overall experience of students during their education, and output variables are the expectations of what the income and life experience of a graduate is likely to be. While the last is probably the most important determinant, especially given the degree of debt with which students are graduating and the fact that many specialists can earn 2-3 (or more) times as much as a primary care physician, it is also the area that schools have the least ability to influence. As Mullan and colleagues have emphasized, medical schools can influence the process variables, including the school’s vision and mission, the teaching of social mission, determinants of health, disparities, and other areas in their classrooms and clinics, experiences for students to serve such as free clinics, and mentoring and role modeling by faculty. However, making these changes seem to be insufficient to overcome the negative influence of the output variables in terms of students choosing primary care and practice in underserved areas. At least for most of the students currently in medical school.

Which brings us to the input variable: who is admitted? Clearly, from the data cited above, medical schools are not taking appreciable numbers of students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups, at least not in anything close to the proportion in the population. They take, on the whole, white (and Asian) students from well-to-do suburbs of large cities who, not coincidentally, went to the “best” public and private schools and have the highest grades and Medical College Admissions Test (MCAT) scores. The problem for the health of the American people is that the strongest predictor of where a medical student will practice is where they come from; minority students are far more likely to practice in minority neighborhoods, rural students are far more likely to practice in rural areas, and white upper middle class students from the suburbs are more likely to practice in the suburbs. These are the areas that already have enough physicians (and sometimes too many). In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people. The imbalance of physicians practicing in health professions shortage areas (HPSAs) vs other areas is demonstrated in the attached table from Zhang, et al.[7]

Yes, our society must urgently address the “output variables” to ensure that students who choose primary care can earn a reasonable proportion of what other specialists do (some studies indicate that 70% of mean specialist income would be sufficient to eliminate that as a reason for not choosing primary care). Indeed, medical schools need to address the “process variables” by having explicit curricula on health disparities, social determinants of health, and community and preventive health, and ensure there is not a “hidden curriculum” mitigating against primary care. But they also urgently need to ensure that most of their admissions, not a token number, are students whose characteristics mean they are more likely to meet America’s healthcare needs. These include demographic characteristics, such as rural or minority origin and lower socioeconomic status of their family, and individual characteristics identified by past performance (not sentiments in an essay). This is primarily significant volunteer service, especially major commitments like the Peace Corps, Americorps, Teach for America, etc.

And, most importantly, these changes and programs must happen at all medical schools and for the bulk of the classes. The time for experiments and pilot programs is done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”. And now is not too soon.

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[1] Mullan, F, Social Mission in Health Professions Education: Beyond Flexner, JAMA published online June 26, 2017. doi:10.1001/jama.2017.7286

[2] Mullan  F, Chen  C, Petterson  S, Kolsky  G, Spagnola  M.  The social mission of medical education: ranking the schools.  Ann Intern Med. 2010;152(12):804-811

[3]  Freeman J, Delzell J, Medical School Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med 2012;44(9):613-4.

[4] Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016, Fam Med 2016;48(9):688-95, (online Table A).

[5] Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 -- Racial and Ethnic Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18, 1994DOI: 10.1056/NEJM199408183310712

[6] https://www.aamc.org/data/facts/

[7] Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA, Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008 May 15;77(10):1378.

Beyond Flexner 2016: Medical schools still need to up their social mission

The “Beyond Flexner 2016” Conference was held in Miami September 19-21, 2016. It was the third in this series of conferences, originally stimulated by the 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”[1]. The first conference, held in Tulsa in 2012, featured the authors of the article and leaders from many “community-based” medical schools founded in 2 rounds of medical school expansion, the 1970s and the 2000s, discussing their real or proposed innovations (Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 1, 2012). The second, held in Albuquerque in 2015, had major growth in attendance, and a group of national speakers who powerfully addressed the failures of both medical schools and our medical system to address the health needs of the American people, especially through (lack of) diversity in our health care workforce, equity (especially racial) in the care provided, and the inadequate numbers of primary care doctors being produced (Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!, April 7, 2015). The metaphor for that blog’s title came from a talk by Don Berwick, in which he compared the US health system to the sturdily-built Choluteca Bridge in Honduras that withstood Hurricane Mitch only to be useless because the hurricane moved the river. (Such a great picture I’m posting it again here!)

The Miami conference, again sponsored by the Josiah Macy, Jr. Foundation along with Florida International University, was very good, although it had some disappointing aspects, notably the attendance, about 350, which was a little less than that in Albuquerque. The speakers were again excellent, with several standouts:  Mona Hanna-Attisha, the pediatrician who exposed the Flint lead poisoning crisis, gave a powerful talk in which she observed that despite being in Michigan, the “mitten state” surrounded by the largest collection of fresh water in the world, Flint’s water even today is still not safe. Robert H. Brook, of the RAND Corporation and UCLA gave a talk where he challenged the “rights” of medical schools, suggesting that hospitals (especially academic medical centers, AHCs) that do not care for their fair share of Medicaid and uninsured patients should not be allowed to have residency training programs, and that, more than allowing community service to count toward promotion and tenure, we should not allow anyone to be promoted without community service. Julio Frenk, the President of the University of Miami, a public health physician who served as Secretary of Health in Mexico, spoke about the need for building social capital that did not just “bond” communities but created “bridges” between them. He also noted that education had to move from the “informative” (providing the knowledge to become a professional) to the “formative” (creating the character and roles that define a professional) to the “transformative”, where professionals could truly create change both in their professions and in society.

One of the new events was the presentation of the First Annual Josiah Macy, Jr. Foundation Awards for Social Mission in Medical Education. The Institutional Award went to Morehouse School of Medicine, the Individual Award to Thomas Curtin, MD of Massachusetts and a leader in establishing Teaching Health Centers, and the program award to the University of Florida for its “Putting Families First” interprofessional education program. The highlight was the presentation of the Lifetime Achievement Award to H. Jack Geiger, whose achievements, from establishing the first Community Health Centers in the US, Physicians for Social Responsibility, Physicians for Human Rights, to serving as Dean of the Sophie Davis School of Biomedical Sciences at CCNY, are enough for several such lifetime awards. Dr. Geiger, who spoke eloquently at the 2015 conference, again addressed the group. He is nearly blind but as powerful and articulate a speaker as ever; he noted that "I have lost most of my eyesight, but it turns out you don't need good eyesight to hang on to a vision!"

In my 2012 blog on the Tulsa Conference, I noted 4 areas I felt were important for focus, and reiterated them writing about the 2015 Albuquerque Conference. They were:

·         Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?

·         Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  primary care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?

·         Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?

·         Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?

There was more emphasis on interprofessional diversity at this conference, with panels including two national nursing leaders (Divina Grossman and Randy Rausch), and a panel including a community (and FQHC) based Dental School Dean (Jack Dillenberg). There was great ethnic and racial diversity in the speakers and moderators, but somewhat less emphasis on diversity in the content of the talks than in 2015. Primary care was still emphasized, but I remain concerned that the conference still features relatively small programs in medical or health professions schools aimed at increasing diversity, primary care, and community engagement. This is, of course, because most such programs are small within their AHCs, and nowhere near as important as the provision of tertiary and quaternary medical care and obtaining NIH research grants. Until these can be scaled up, until producing a majority of graduates entering primary care, enrolling and graduate underrepresented minority and low-income students at least in proportion to their percentages in the population, and working in the community becomes the highest priority of an AHC, the movement is stalled.

It is sometimes tempting to think that AHCs are incorrigible, that they are set in their ways – and in the way that they are financed – and that achieving the goals I have outlined above, or even more modest improvements in social mission – are not going to happen, at least any time soon. The Association of American Medical Colleges (AAMC) supports in word – and to a limited extent in deed – the goals of diversity and community engagement, but not enough to change the core focus of their members. Indeed, tellingly, they continue to call for increasing the number of residency positions, but not on targeting them to primary care, as does the American Academy of Family Physicians (AAFP). The largest specialty in medicine, Internal Medicine, opposes AAFP’s proposal to fund only “first certification” residency positions, as this would not fund their subspecialty fellowships.[2] Thus, they put self-interest (having funded fellows in their subspecialties) ahead of the need for America to have more primary care doctors.

Yes, it can get frustrating to work with medical schools and their entrenched anti-social values. But this is where the medical students are, where they are trained, and where they get their ideas of what might be the most appropriate specialties to enter and what th

e professional role of a physician is – e.g., working in the community or not. They need both individual and institutional role models.

So the need to work for a social mission for medical – and health professions – education is still an important goal.

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[1] Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M,“The social mission of medical education: ranking the schools”, Ann Int Med 15 June 2010, Vol 152, No. 12,

[2] Butkus R, et al. Ann Intern Med. 2016;doi:10.7326/M15-2917.

Medical schools are no place to train physicians

Doctors have to go to medical school. That makes sense. They have to learn their craft, master skills, and gain an enormous amount of knowledge. They also, and this is at least as important, need to learn how to think and how to solve problems. And they need to learn how to be life-long learners because new knowledge is constantly being discovered, and old truths are being debunked. Therefore, they must learn to un-learn, and not to stay attached to what they once knew to be true but no longer is. They also need, in the face of drinking from this fire-hose of new information and new skills, to retain their core humanity and their caring, the reasons that (hopefully) most of them went into medicine.

Medical students struggle to acculturate to the profession, to learn the new language replete with eponyms, abbreviations, and long abstruse names for diseases (many are from Latin, and while they are impressive and complicated, they are also sometimes trite in translation, e.g., “itchy red rash”). They have to learn to speak “medical” as a way to be accepted into the guild by their seniors, but must be careful that it does not block their ability to communicate with their patients; they also need to continue to speak English (or whatever the language is that their patients speak). “Medical” may also offer a convenient way of obscuring and temporizing and avoiding difficult conversations (“the biopsy indicates a malignant neoplasm” instead of “you have cancer”).  But there needs to be a place for them to learn.

So what is wrong with the places that we are teaching them now? Most often, allopathic (i.e., “MD”) medical schools are part of an “academic health center” (AHC), combined with a teaching hospital. They have large biomedical research enterprises, with many PhD faculty who are, if they are good and lucky, are externally funded by the National Institutes of Health (NIH). Some or many of them spend some of their time teaching the “basic science” material (biochemistry, anatomy, physiology, microbiology, pharmacology, pathology) that medical students need to learn. By “need to learn” we usually mean “what we have always taught them” or “what they need to pass the national examination (USMLE Step 1) that covers that material”. This history goes back 100 years, to the Flexner Report of 1910. Contracted by the AMA, educator Abraham Flexner evaluated the multitude of medical schools, recommended closing many which were little more than apprenticeship programs without a scientific basis, and recommended that medical schools be based upon the model of Johns Hopkins: part of a university (from the German tradition), grounded in science, and based in a core curriculum of the sciences. This has been the model ever since.

However, 100 years later, these medical schools and the AHCs of which they are a part have grown to enormous size, concentrating huge basic research facilities (Johns Hopkins alone receives over $300 million a year in NIH grants) and tertiary and quarternary medical services – high tech, high complexity  treatment for rare diseases or complex manifestations of more common ones. They have often lost their focus on the health of the actual community of which they are a part. This was a reason for two rounds of creating “community-based” medical schools, which use non-university, or “community”, hospitals: the first in the 1970s and the second in the 2000s. Some of these schools have maintained a focus on community health, to a greater or lesser degree, but many have largely abandoned those missions as they have sought to replicate the Hopkins model and become major research centers. The move of many schools away from community was the impetus for the “Beyond Flexner” conference held in Tulsa in 2012 (see Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 16, 2012) and for a number of research studies focused on the “social mission” of medical schools.

The fact is that most doctors who graduate from medical school will not practice in a tertiary AHC, but rather in the community, although the other fact is that a disproportionate number of them will choose specialties that are of little or no use in many communities that need doctors. They will, if they can (i.e., if their grades are high enough) often choose subspecialties that can only be practiced in the high-tech setting of the AHC or the other relatively small number of very large metropolitan hospitals, often with large residency training programs. As they look around at the institution in which they are being educated, they see an enormously skewed mix of specialties. For example, 10% of doctors may be anesthesiologists and there well may be more cardiologists than primary care physicians. While this is not the mix in world of practice, and still less the mix that we need to have for an effectively functioning health system, it is the world in which they are being trained.

The extremely atypical mix of medical specialties in the AHC is not “wrong”; it reflects the atypical mix of patients who are hospitalized there. It is time for another look at the studies that have been done on the “ecology of medical care”, first by Kerr White in 1961 and replicated by the Robert Graham Center of the American Academy of Family Physicians in 2003 (see The role of Primary Care in improving health: In the US and around the world, October 13, 2013), and represented by the graphic reproduced here. The biggest box (1000) is a community of adults at risk, the second biggest (800) is those who have symptoms in a given month, and the tiny one, representing less than 0.1%,  is those hospitalized at an academic teaching hospital.  Thus, the population that students mostly learn on is atypical, heaving skewed to the uncommon; it is not representative of even all hospitalized people, not to mention the non-hospitalized ill (and still less the healthy-but-needing-preventive care) in the community.

Another aspect of educating students in the AHC is that much of the medical curriculum is determined by those non-physician scientists who are primarily researchers. They not only teach medical students, they (or their colleagues at other institutions) write the questions for USMLE Step 1. They are often working at the cutting edge of scientific discovery, but the knowledge that medical students need in their education is much more basic, much more about understanding the scientific method, and what constitutes valid evidence. There is relatively little need, at this stage, for students to learn about the current research that these scientists are doing. Even the traditional memorization of lots of details about basic cell structure and function is probably unnecessary; after 5 years of non-use students likely retain only 10% of what they learn; even if they need 10% -- or more – in their future careers, there is no likelihood that it will be the same 10%. We have to do a better job has of determining what portion of the information currently taught in the “basic sciences” is crucial for all future doctors to know and memorize, and we also need to broaden the definition of “basic science” to include the key social sciences of anthropology, sociology, psychology, communication, and even many areas of the humanities such as ethics. This is not likely to happen in a curriculum controlled by molecular biologists.

Medical students need a clinical education in which the most common clinical conditions are the most common ones they see, the most common presentations of those conditions are the most common ones they see, and the most common treatments are the ones they see implemented. They need to work with doctors who are representative, in skills and focus, of the doctors they will be (and need to be) in practice. Clinical medical education seems to work on the implicit belief that ability to take care of patients in an intensive care unit necessarily means one is competent to take care of those in the hospital, or that the ability to care for people in the hospital means one can care for ambulatory patients, when in fact these are dramatically different skills sets.

This is not to say that we do not need hospitals and health centers that can care for people with rare, complicated, end stage, tertiary and quarternary disease. We do, and they should have the mix of specialists appropriate to them, more or less the mix we currently have in AHCs. And it is certainly not to say that we do not need basic research that may someday come up with better treatments for disease. We do, and those research centers should be generously supported. But their existence need not be tied to the teaching of medical students. The basic science, and social science, and humanities that every future doctor needs to learn can be taught by a small number of faculty members focused on teaching, and does not need to be tied to a major biomedical research enterprise. Our current system is not working; we produce too many doctors who do narrow rescue care, and not enough who provide general care. We spend too much money on high-tech care and not enough on addressing the core causes of disease.

If we trained doctors in the right way in the right place we might have a better shot at getting the health system, and even the health, our country needs.

Why don't graduate medical education programs produce the doctors America needs?

In 2010, Fitzhugh Mullan and others from the George Washington University, with collaborators from the American Academy of Family Physicians' (AAFP) Robert Graham Policy Research Center, published the seminal article “The social mission of medical education: ranking the schools” in the Annals of Internal Medicine (discussed in this blog on June 10, 2010 in A New Way of Ranking Medical Schools: Social Mission).  This paper looked at the production of medical schools in the US in terms of whether their graduates were in 3 categories associated with social mission: practice in an underserved area, practicing a primary care specialty, and having a higher percentage of graduates who were members of underrepresented minority groups.  It was the first time such data had been published, and the results showed that most medical schools don’t do very well, and that, in general, those that do the worst are those most often identified as “top” schools by criteria such as National Institutes of Health (NIH) funding or rankings by US News. This is not surprising; enrolling students from high income families who have had top grades at the most elite private and suburban schools, training them in a setting in which the mix of doctors is heavily skewed to the most subspecialized and research-intensive, located in a densely populated urban area, is the precisely wrong formula for recruiting physicians from underserved backgrounds and training them to practice primary care in areas of need. Unfortunately, although there have been small programs implemented at many schools, this model has not seen any significant change in most medical schools, particularly those “most elite”.

This year, this group from the Graham Center and George Washington, with collaborators from the the American Board of Family Medicine (ABFM), take the next obvious step in examining the production of the nation’s doctors. In “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,[1] in Academic Medicine (not available free on-line; abstract at http://www.ncbi.nlm.nih.gov/pubmed/23752037), Candice Chen and her colleagues look at how institutions that sponsor GME (and, importantly, get very large amounts of money from Medicare and Medicaid -- $9.3 billion and $3.18 Billion, respectively, in 2009) do in producing specialists in short supply: primary care physicians (defined as family medicine, general internal medicine (GIM), general pediatrics, internal medicine–pediatrics, internal medicine geriatrics, and family medicine geriatrics), general surgeons, obstetrician - gynecologists and psychiatrists. Identifying which program produced who is quite a bit harder than when looking at medical school outcomes; while a medical school is a medical school, GME-sponsoring institutions can be consortia of a medical school and one or more hospitals, and may often sponsor more than one residency program in the same specialty.

As in all measures of primary care production, the big complication is in graduates of internal medicine programs, the majority of whose graduates go into subspecialty (e.g., cardiology, gastroenterology, pulmonary and critical care) fellowships rather than remaining in primary care/general internal medicine (GIM). Chen’s work accounts for this, but explicitly notes that they are unable to account for the percent of GIM graduates who do not go on to subspecialty training but work as hospitalists. These are clearly not in primary care, and by many accounts may represent a majority of those completing the basic internal medicine training but not going on to fellowship. The authors note that, by their calculations, the average for primary care was 25.2%,”… this overestimates primary care production, as we could not account for primary care physicians practicing as hospitalists.”

Just as with medical schools, there was a wide variation in the percent of graduates of different sponsoring institutions who entered these specialties-in-need. Of 759 sponsoring institutions, they ‘…found that 158 institutions produced no primary care graduates, and 184 institutions produced more than 80%; the latter tended to be smaller institutions.” Again no surprise; the larger, more elite and famous sponsoring institutions (most often hospitals associated with elite medical schools) did a terrible job, while the smaller sponsoring institutions -- often hospitals with one (usually family medicine) or a few residencies, in smaller cities and towns, and affiliated with Federally-Qualified Health Centers (FQHCs) or Area Health Education Centers (AHECs), based in in underserved urban and rural communities, did well. The Robert Graham Center website provides interactive tools to allow you to map the density of primary care physicians by state, county and other areas, the output of each institution producing residents in terms of location and specialty, and the footprint of graduates from each GME program.

Let me restate: 158 institutions sponsoring graduate medical education produced NO primary care graduates! Let’s add some other numbers from the study: 198 institutions (more than 25% of the total) produced NO rural physicians, while only 10 institutions had all graduates go to rural areas; the average percentage of graduates providing direct patient care in rural areas was 4.8%. 283 institutions (37%) produced NO physicians practicing in FQHCs or rural health clinics (RHCs); 479 (63%!) institutions produced no National Health Service Corps (NHSC; a program for sponsoring physicians for underserved areas) physicians. This performance can be described by a single, simple word: ABYSMAL!

Elite academic medical centers have values that lead them to attract and select students and trainees with characteristics that are the opposite of those needed for training physicians to meet the needs of the American people. They value caring for rarer and highly specialized tertiary and quarternary conditions, which both are highly reimbursed and provide the basis for research in narrow areas of disease (and almost never of health). They value receiving large sums of money from the National Institutes of Health (NIH) for research, most of which is basic laboratory research. These are not bad values; they are, in fact, necessary. We need research, including basic laboratory research and first-in-human studies, for medical science to advance (although we also need a lot more funding for population-based research into the causes of health and disease, and community-based efforts to address them). We need tertiary-care medical centers where rarer or more complex conditions can be most effectively treated by physicians and surgeons whose narrower expertise makes them more experienced and effective.

The problem is that concentrating all these subspecialists in the very places where students and residents are trained gives those learners a very skewed idea of the ratio of subspecialists to primary care doctors, and makes the teachers want to get the “best” students to go into their narrow, subspecialized areas. In addition, selection for medical school (and to a large extent for residencies that are more competitive because they have fewer slots) tend to be for students who have the characteristics that help them to do well in basic science courses, standardized tests, and possibly in laboratory research. These students tend to come from the highest income families of professionals, in the largest metropolitan areas, from elite public or suburban schools. They look a great deal like the people who have plenty of doctors to care for them, and very little like the people whose communities suffer from a dearth of physicians in inner city and rural areas. I have previously noted that, while about 20% of Americans live in rural areas, only about 9% of doctors practice in such areas; this study shows it is actually much worse, with only 4.8% of graduates in rural practice!

The situation is exacerbated by the inequity in income between primary care doctors and subspecialists, an inequity also seen (albeit at a higher level) for general surgeons vs. subspecialty surgeons, especially when hours of work are considered. Thus, students, generally selected from a population not representative of the American people, who have increasing debt (even for those from upper-middle-income, not to mention middle-income and the rare student from low income families), are attracted to specialties that pay the most; if assessments of “lifestyle” are added to the calculus, those that pay the most for the least work (or whose income/work ratios are the highest). This is a formula to continue what we have, not to make things better.

The authors of the paper say that “Primary care physician production of 25.2% and rural physician production of 4.8% will not sustain the current workforce, solve problems of maldistribution, or address acknowledged shortages. The relatively small number of physicians choosing to work in RHCs, FQHCs, HPSAs, and the NHSC will not support a doubling of the capacity of safety net services envisioned by the

Affordable Care Act.” They have that right. Medical schools and GME-sponsoring institutions have for too long been allowed to continue being self-serving, with the biggest institutions being entirely pitiful in terms of producing the doctors America needs. It needs an immediate, far-reaching, large-scale change, where the biggest training programs see themselves in the business of producing primary care doctors for underserved people.

Why would they do that? Well, there is the $9.5 billion in Medicare and $3.18 billion in Medicaid GME funding that could be withheld if they don’t, for a start…

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[1] Chen C, et al., “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,  Academic Medicine, Vol. 88, No. 9 / September 2013

Beyond Flexner: Taking the Social Mission of Medical Schools to the next level

In my blog entry for June 20, 2010, A New Way of Ranking Medical Schools: Social Mission, I discussed the article by Mullan, Chen and colleagues that had just been published in in the Annals of Internal Medicine, “The social mission of medical education: ranking the schools”. That seminal article provided concrete data on how medical schools ranked based on 3 criteria related to social mission: percent of underrepresented minority students in their classes, percent of graduates practicing in health professions shortage areas (HPSAs) and percent of their graduates actually practicing in primary care following their residency training. Unsurprisingly, the schools at the top of these rankings were a very group than those at the top than of more traditional rankings, such as US News and World Report, which are based on criteria like reputation, selectivity (what percent of applicants are rejected?) and research funding from the National Institutes of Health (NIH). Indeed, those schools that tend to rank at the top in the latter set of criteria were generally at the bottom of the list in social mission.

It didn’t make those traditional "powers" happy to be ranked at the bottom, and so they did the two things usually done by people and organizations who are found to be lacking by the data: they denied that it was true, that somehow the data was wrong, and they attacked the values of social mission, saying, in essence, that the characteristics being measured by the social mission rankings were not the important ones. The important criteria, of course, were those in which they -- the schools ranked low in social mission and high in traditional rankings – did well. Denying the truth of the study was hard, because the statistics used for measuring the 3 social mission criteria were not inaccurate. Mostly, then, their argument was “Oh, that data is old. We are better now!” But the reason the authors looked at graduates from 1999-2001 was that it allowed them to see several years after completing their primary residency training, not only whether graduates were really practicing in HPSAs, but whether they were really practicing in primary care. Medical schools like to count all students entering internal medicine residencies as “primary care”, when only a small percent do not enter subspecialty fellowships or practice as hospitalists and actually end up in primary care. And, in fact, in that 8 year interval, in the first decade of the 2000s, the numbers got worse.

So these critics mostly focused on the second defense, downgrading the importance of social mission. The measures they suggested (which they do well on) were: 1) getting a lot of money to do research (a little self-fulfilling, since the NIH panels that award research grants are largely staffed by people at the institutions that get research grants; in addition, this research is overwhelming done in the basic biomedical laboratory or early clinical trials, not in the community or the general population); 2) having a great reputation so that faculty who want to get big research grants want to come work there and students with high grades, mostly from the elite upper and upper middle class, want to attend, and 3) having a great reputation, so “peer” evaluators will say “yeah, you’re good!”

One can reasonably argue that the 3 criteria examined by Mullan and colleagues do not completely reflect the social impact of medical schools. Other criteria might include creation of community training experiences, community involvement and engagement in providing venues for training and in determining the type of research carried out by medical school investigators, the degree to which research and programs carried out by the medical school decrease health disparities, and the degree to which the health of communities and populations are increased by the activities of the medical school in practice, research, and education. However, these are not the criteria that the traditional “top” schools want to be evaluated on. The fact is that they are doing what they do, and what they do does not address diversity of the workforce, disparities in health, community involvement, or modern models of interprofessional education.

The next step in the Social Missions of Medical Education movement occurred in Tulsa, OK, May 16-18, 2012 at the “Beyond Flexner” conference. 100 years ago Abraham Flexner was commissioned by the Carnegie Foundation to look at medical education in the US. As a result of his report, more than half of US medical schools closed. Those that remained were largely the ones that had adopted a scientific basis for their medical education and were based in or tightly tied with research universities. For over a half-century, these schools grew with emphasis on the biomedical research enterprise and the training of highly skilled subspecialists, and little interest in any kind of social mission. The social movements of the 1960s and 1970s saw the first large number of new medical schools, and then quiescence until this decade, with a number of additional schools being created. Many of those in both the 1970s and 2000s groups manifested, at least initially, a social mission – that is, they had the goal of actually producing doctors and research that would improve the health of the population.

“Beyond Flexner” was co-sponsored by Mullan’s Medical Education Future Studies group from George Washington University and the new University of Oklahoma-Tulsa School of Community Medicine, led by Dr. Gerry Clancy, President of OU-Tulsa. Under Dr. Clancy, OU-Tulsa has transformed from a site for clinical training of a portion of the students from the OU School of Medicine in Oklahoma City to become the first 4-year school officially called “Community Medicine”. It was also one of the 6 schools that were part of the follow-up study of social mission, and whose leaders presented some of their innovations and successes at the conference. Three, including OU-Tulsa, Florida International University, and the AT Still College of Osteopathic Medicine in Arizona, are in the newest group, and have yet to graduate a class. Their contribution was largely in the creative and innovative methods that they are using to select and enroll and educate students, emphasizing diversity, community-based education, dispersion of educational settings, ambulatory (rather than hospital-based) training, emphasis on primary care and concern for the social determinants of health and health disparities. (A fourth new school, the University of Northern Ontario, in Canada, was also part of this group.)

The 3 other schools were part of the prior wave of new schools created in the 1970s and have had significant social impact, Morehouse University, the Southern Illinois School of Medicine, and the University of New Mexico School of Medicine. These are certainly not the only schools that have made a major commitment to social mission, and perhaps they are not in all respects the perfect exemplars, but they are certainly among the leaders in the field. They are part of an international movement of medical schools that were founded in the same period, to create physicians who would have the skills to care for people (primary care), have the knowledge to do research on community and population health, have the relationships to train and work with people in community settings, and have the intelligence to challenge traditional methods of classroom teaching by increasing clinical and interprofessional training experiences. Representatives from these and other schools described pipeline programs, interprofessional training, dispersion of training sites, innovative curricula, emphasis on primary care, and many other models and efforts.

The bottom line is that outcomes matter, and that judging a school by the impact that it has on the health of the population is the gold standard. Biomedical research contributes important knowledge that may, someday, impact human health, but this can be done in research institutes (see, for example, Karolinska, Rockefeller, Insitute Pasteur, Stowers) and certainly should not determine the core mission of schools focused on training doctors and other health professionals. The steering committee of “Beyond Flexner” is developing key principles that need metrics to assess outcomes; I would suggest the following:

·       Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?

·       Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?

·       Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?

·       Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?

Maybe by the time of the next “Beyond Flexner” conference, every one of our medical education institutions will have bought into these principles and their implementation, and be able to be examples of how it can and should be done.

Beyond Flexner Conference on the Social Mission in Medical Education

"Beyond Flexner: Social Mission in Medical Education", to be held in Tulsa May 15-17, promises to be a major conference in addressing and enhancing the social missions of medical and other health professions education.

Chaired by Fitzhugh Mullan, MD, of George Washington University and the Medical Education Futures Study, and Gerald Clancy, MD, President of the University of Oklahoma - Tulsa and Dean of the School of Community Medicine there, feature speakers will include David Satcher, MD and H. Jack Geiger, MD.

I have no idea whether others will bring this up, but I am again motivated by having recently reviewed the literature on why under-represented minority college students who want to become doctors don't end up applying. Barr, et al, found a negative experience in a chemistry course was the single largest cause[1]. How much is the ability to use complex chemistry important in a physician compared to commitment to meeting social missions? Indeed, other than passing the first two years of classes and USMLE I, is it useful at all?


I hope that these are the kind of issues we address.

I will be there and look forward to joining a lot of enthusiastic and creative colleagues!


[1] Barr DA, Gonzalez ME, Warant S. The Leaky Pipeline: Factors Associated With  Early Decline in Interest in Premedical Studies Among Underrepresented Minority Undergraduate Students, Acad Med, 2008; 83:503–511.

A New Way of Ranking Medical Schools: Social Mission

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In the June issue of the Annals of Internal Medicine, Fitzhugh Mullan, Candice Chen, Stephen Petterson, Gretchen Kolsky, and Michael Spagnola, mostly from the Department of Health Policy at the George Washington University (and one from the Robert Graham Center) report on “The social mission of medical education: ranking the schools”. This study, sponsored by the Josiah Macy, Jr. Foundation as part of the Medical Education Futures Study (MEFS) is the first report to look at this area, and should be eye-opening to those who assume that “good” medical schools are “good” at everything. Most ranking systems, most notably those of US News and World Report, are based on NIH research funding, grades and test scores of entering students, “competitiveness” (how low a percent of applicants they accept) and reputation. Obviously, the grades and test scores are related to competitiveness and reputation is a tautology, because it reinforces itself. It should depend upon what you are looking at, of course. I addressed this in “Rankings of Medical Schools: Do they tell us anything?” (September 25, 2009), and observed that what they tell us is who does well in what is measured, and that this should only be important to us if those are the outcomes we value.

Mullan and colleagues evaluate different outcomes, the degree to which medical schools meet their “social mission”, or to put it another way, the degree to which they produce the physicians that will take care of the American people. More to the point, since it can be argued that most medical school graduates take care of some American people, physicians who will take care of those people who need it the most because they don’t already have doctors. This means largely those in poor communities, rural communities, and minority communities (and especially those communities that are two or three of these). They look at 3 characteristics of graduates: 1) what percent of their graduates are practicing primary care, 2) what percent of their graduates are practicing in designated Health Professions Shortage Areas (HPSAs), and 3) what percent of their graduates are members of underrepresented minority groups? This is pretty straightforward, and they take two other steps to try and ensure that this is an accurate reflection.

The first is that they examined students, in the graduating classes of 1999-2001, 8 years after graduation. As I have pointed out several times (Primary Care and Residency Expansion, January 7, 2010; Funding Graduate Medical Education, May 25, 2009), the “credit” medical schools claim for students entering “primary care” residencies includes all those entering internal medicine programs, the vast majority of whom will enter subspecialty training. By looking at students 8 years after graduation, after they have completed residency and subspecialty fellowship training, they are able to get a much more accurate picture of who is actually doing primary care. Similarly, it also means that those who are practicing in HPSAs have been doing it for several years. Overall, public schools did much better than private schools, and Southern, Midwestern, and Western schools better than Northeastern schools.

In terms of underrepresented minority students, the percent of graduates, for public medical schools, is compared to the percent of the underrepresented minority population for the state, while for private schools, which are presumed to draw from a more national base, it is the national percentage (26.5%). Thus, for example, the University of Iowa has a positive ratio with 8.1% minority students in a state that is only 6% minority, while the Universidad de Puerto Rico en Ponce has a negative ratio because, even though their students are 82.5% underrepresented minorities, their “state” is 98.8%. The underrepresented minority scores for the 3 historically black medical schools, Morehouse, Meharry and Howard are so high, compared to the national average (as they are all private) that they are easily the top 3 in the overall social mission score. This tends to wash out the significant differences between them on the other two areas. For example Meharry does well in producing primary care physicians (49.3%, or 2 standard deviations [SD] above the national mean) compared to Howard, which at 36.5% is only 0.19 SD above the mean; Howard, however, does better at placing students in HPSAs (33.7%, +0.78 SD) than Meharry (28.1%, +0.12 SD). Ponce, despite its negative underrepresented minority score and also a negative primary care physician score (-0.31 SD*), ranks #9 nationally in total social mission score. This is based on its high rate of physicians practicing in HPSAs (43.8%, +1.94 SD), because so much of its service area are HPSAs.

The data can be analyzed in a number of ways. Osteopathic schools have a much higher rate of producing primary care doctors, but none were in the top 20 because their percent of underrepresented minorities are low. Adding only the two dimensions of primary care and HPSA practice shows only 7 schools with a standardized score above 3, all of them public allopathic schools and 4 of them “community based” medical schools with a specific commitment to primary care (as is Wright State, the #4 ranked school in overall social mission). A few top NIH research schools (4, to be exact) “defied the trend” and were in, at least, the top quartile of social mission scores, again all public schools. Other than the historically black schools, private schools were nowhere to be seen.

The schools that traditionally do well on rankings such as that of US News tended to be at the bottom of this scale. They are overwhelmingly private (14 of the bottom 20) and generally highly NIH-funded. Comments from the leaders of those schools, unsurprisingly, tended to disparage the study and its methods, and to assert, essentially, that “our school does well on all of its missions.” If those missions include the social missions of meeting the health needs of the American people by producing minority and primary care physicians, and those that practice in underserved areas, they clearly do not. And, while some are better than others, no medical schools are doing very well at enrolling underrepresented minorities (except the historically black schools and the Puerto Rican schools) or at producing physicians for rural areas at anything approaching the percent of Americans who live in those areas (Primary Care and Rural Areas, April 28, 2010).

This is not to say that other missions of medical schools, such as biomedical research, cutting-edge medical care, and training of the future generations of academics, including the MD/PhDs who will be laboratory-based researchers, are unimportant. Lawrence G. Smith and Veronica M. Catanese emphasize this point in their accompanying editorial, “The Many Missions of Medical Schools”, as well as noting various possible ways in which the production of physicians who fulfill a social mission might have been underestimated by Mullan, et. al. They also note, as I have above, that different schools do better or worse on the different social mission measures, but also that success in the social mission needs to be pursued, as success in all other missions: “The lack of concordance among the 3 elements of Mullan and colleagues' social mission score suggests that medical schools that accept this mission—as they must—cannot define social mission narrowly. They must have multipronged initiatives and not simply 'wait' for programs aimed at recruiting and retaining underrepresented minority students, or at specifically incentivizing primary care, to bear fruit.”

The key point is that the data produced by Mullan and colleagues that shows that schools which are historically highly ranked do relatively poorly in social mission is not due to a flawed methodology. “The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas.” It is because these schools do not emphasize the characteristics that they are measuring, combined into the concept of social mission, nearly as highly as they do their other missions and do not put as much energy, time, or especially money into them. Mullan et. al. conclude that “Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation. A diverse, equitably distributed physician workforce with a strong primary care base is essential to achieve quality health care that is accessible and affordable, regardless of the nature of any future health care reform.”

The authors note that “Medical schools, however, are the only institutions in our society that can produce physicians”. It is up to the people of the US, particularly the communities in need and the policy makers who represent them, to decide how high a priority producing physicians who will meet our social need by practicing in specialties, in areas, and with populations who do not have doctors, and how to use the public coffers to achieve this. The time is long past, however, for these characteristics not to be measured. We can no longer, in self-indulgence or ignorance, assume that those schools that are the “best” on US News rankings because of NIH research funding, selectivity, and “reputation” are the best in every area. In producing the doctors most needed by this nation’s most needy, they are, with few exceptions, mostly the worst.

*Like the other Puerto Rican Schools, Ponce has a low production of family physicians, ranking 117 out of 128 medical schools for producing FPs in the 10 years from 1999-2008, as reported by the American Academy of Family Physicians (AAFP) annual analysis.
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