editorial: Medical Education in the United States: Are We Building a Multitiered System?

On first glance, it might seem out of place to discuss medical education in a journal devoted to the clinical and translational sciences. So let me first try to convince you that medical education is an important element that will serve as a foundation for the advances in the clinical and translational sciences that we all hope to achieve. I put forward four arguments to support my belief. First, the future of our field depends on our ability to attract competent and committed physician‐scientists and clinician‐investigators to translational medicine. Second, we must have a population of practicing physicians that intuitively recognize the importance of effectively translating new discoveries to the care of patients in the community. Third, we need to teach that important contributions will come from practicing physicians who can identify the unusual patient or recognize a family with a clearly heritable disease and link those patients with the appropriate translational investigators. And finally, we must teach our students the fundamentals of clinical research and bioethics in order that they can incorporate clinical or outcomes research in their practices. At a time when new discoveries are changing the face of medicine on a daily basis, a strong foundation in the clinical and translational sciences will also enhance a physician’s clinical capabilities.

…all medical schools should be required to institute didactic course work in the clinical and translational sciences including bioethics, clinical trial design and biostatistics.

Now, let me try to convince you that accomplishing the aforementioned goals may be difficult at some of the new medical schools that are open or planned. In 2006, the Association of American Medical Colleges (AAMC) called on medical schools across the country to increase their enrollments by 30% by 2015 in order to address the looming crisis in the health care workforce. Many schools responded by increasing the class size on their own campus or building branch campuses. For example, the Medical College of Georgia School of Medicine is developing a 4‐year branch campus program in Athens. ¹ Other schools and states have taken a different approach by establishing new medical schools. Some of these new schools are embedded in existing universities (Florida International University, University of Central Florida, Texas Tech University Health Sciences Center, and Oakland University William Beaumont School of Medicine), one represents a partnership between a university and a major health care system (Virginia Tech Carilion School of Medicine), and at least one new school has no university affiliation whatsoever (The Commonwealth Medical College). Two schools are presently seeking preliminary accreditation, Hofstra University School of Medicine and Cooper Medical School of Rowan University. ²

The structure of some of these new medical schools raises substantive concerns about their ability to educate the next generation of physicians. For example, the “branch campus” that is distant from the main medical school campus presents unique challenges. These were first pointed out at the turn of the 20th century by Abraham Flexner. ³ He noted that: “The divided school begins by inheriting a serious problem. Its laboratory end, situated at the university, has been recently constituted of modern men: the clinical end, situated in a city at some distance is usually what is left of the old‐fashioned school which the university adopted in taking on its medical department….But the separation of its clinical branch, with the increasing absorption of the teachers in practice, involves constant danger of fresh alienation.” Although tele‐medicine and the internet may mitigate some of the problems Flexner identified, the primary concerns regarding separating the basic and clinical sciences remain.

Other new medical schools will also present challenges in creating an environment that supports clinical and translational research. The new Virginia Tech Carilion School of Medicine in Roanoke intends to model itself on Harvard Medical School’s health sciences and technology program and Cleveland Clinic’s Lerner College of Medicine. In addition to the traditional medical school curriculum, the 40 students enrolled in each class will receive training in research methods and all students will be expected to participate in original research and to write a thesis prior to graduation. Yet with only $10 million in total research grants, a number that ranks them 185th among all US institutions receiving National Institutes of Health (NIH) funding, it is not clear that Virginia Tech, located 40 miles from the medical school campus, will be able to support an intellectual and scientific environment that replicates those at Harvard or at the Cleveland Clinic. Building a research environment on the campus of the new medical school will have its own challenges. ⁴

The new Commonwealth School of Medicine is an example of a freestanding medical school. Opened last year in Scranton, a city in northeastern Pennsylvania whose population has declined to just 70,000 inhabitants, the school was opened to increase the number of physicians in Northeastern Pennsylvania, create new jobs, and have a positive impact on the local economy. ⁵ , ⁶ It has no affiliation with any of Pennsylvania’s existing medical schools or research universities and it will use a group of small community hospitals for its teaching programs. The students will be taught by community physicians; however, unlike the new schools in other areas, these faculty members have no ties to an existing medical school and/or university. The guidelines of the Liaison Committee on Medical Education (LCME) state that a medical school “should be a component of a university offering other graduate and professional degree programs that contribute to the academic environment of the medical school [and] the program of medical education leading to the M.D. degree must be conducted in an environment that fosters the intellectual challenge and spirit of inquiry appropriate to a community of scholars…” It is unclear how the new school will meet the requirements of the LCME without an affiliation with a university.

I was most troubled by a recent announcement by the Texas Tech University Health Sciences Center School of Medicine in El Paso, Texas. This new medical school has created the first 3‐year medical degree ever approved by the LCME. Called the Family Medicine Accelerated Track, the program will allow primary care students to complete their degrees in 3 years at half of the cost of the standard 4‐year program. According to Michael Ragain, M.D., Braddock Chair of the Department of Family and Community Medicine, “with programs such as this, we can double the number of primary care physicians available to care for the US population.” ⁷ It is difficult for me to believe that we can adequately teach everything that is important to know about medicine in 3 years—much less introduce students to the clinical and translational sciences. The new program appears to make the assumption that the family physician can complete their training in 3 years because they do not need to know as much as other students. I would proffer the opinion that it is just the opposite. As Abraham Flexner remarked: “In the first place, the small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on; he cannot in every pinch hail specialist, expert and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best trained physician that can be induced to go there.” ³

Another new medical school that is taking shortcuts is the school proposed for Hofstra University. It will have no basic science departments. In an interview with the Wall Street Journal health blog about the cost of starting the new school, Lawrence G. Smith, dean of the soon to be opened school said. “We are not going to create any of those departments [anatomy, physiology, pharmacology], I want to link things so if we’re learning anatomy and physiology of the heart, we let students get into the operating room and look at open heart surgery to see not the perfect world of the textbook but the real world.” ² Based on my own experiences, I would argue that there is little to be learned in terms of the molecular and cellular pathobiology of the heart from peering over a surgeon’s shoulder. Without a strong underpinning in the basic sciences, it will be difficult for students to appreciate the many aspects of the clinical and translational sciences. More importantly, it is unclear how a student will be able to fully appreciate new discoveries that apply basic science technology such as genomics and proteomics to the every day care of patients without a firm foundation in biochemistry, cell biology, and genetics.

I also worry that less than half of US medical schools will have centers for clinical and translational sciences. Invariably, we tend to look at other medical schools as our competitors. We compete for patients, for grants, for philanthropic gifts, and for faculty and as the health care marketplace has shrunk, the competition has become fierce—particularly in cities with multiple academic medical centers. However, those of us who pursue clinical and translational science research must recognize that we will hurt ourselves if half of the students graduating from America’s medical schools do not appreciate the value of translational research. Without a practice community that has been schooled in at least the fundamentals of clinical and translational research, it will be difficult if not impossible to rapidly translate science to the community.

So what can we do to insure that we don’t have a multitiered educational system in the United States? Medical education is regulated at the state level. Therefore, we must first work with our state legislatures to insure that new medical schools that are created in response to the growing workforce crisis are providing a level of training that is consistent with existing medical schools in the state both at the clinical and preclinical levels. Second, we must use whatever powers of persuasion we have with state and national associations to oppose the creation of additional short‐track medical school programs until it can be clearly documented that the students educated in the first such program received an adequate education. The 3‐year graduates may need to be evaluated with more than simply a standardized test to insure that they are clinically capable. Once the 60 Clinical and Translational Science Awards (CTSA) centers are identified, individual awardees should work assiduously to partner with local or regional medical schools that lack a CTSA center. Few medical schools are altruistic; therefore, the NIH should both encourage and incentivize constructive collaborations between academic medical centers. Medical schools without CTSA should focus their resources on creating centers of excellence in the clinical and translational sciences that facilitate collaborative and multidisciplinary research. And finally, all medical schools should be required to institute didactic course work in the clinical and translational sciences including bioethics, clinical trial design, and biostatistics. Only if we invest in medical education today will we have the translational investigators of tomorrow.