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Educational Programs in US Medical Schools, 2003-2004
Barbara Barzansky, PhD;
Sylvia I. Etzel
JAMA. 2004;292:1025-1031.
ABSTRACT
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Context US medical schools continue to change their organizational structures, staffing patterns, and educational programs.
Objective To review the status of US medical school educational programs in the 2003-2004 academic year, compared with 1993-1994.
Data Sources The Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire for 2003-2004 and the Association of American Medical Colleges Directory of American Medical Education for the years 1983-1984, 1993-1994, and 2003-2004.
Data Synthesis The number of full-time faculty members in the 126 LCME-accredited medical schools increased from 90 975 in 1993-1994 to 114 549 in 2003-2004 (+26%), whereas the number of enrolled students remained essentially unchanged (66 453 in 1993-1994 and 67 166 in 2003-2004). In 2003-2004, 48% of medical school deans held another title at the medical center or university level, such as vice president for health affairs. There are 94 medical schools that have a comprehensive clinical examination using the standardized patient/objective structured clinical examination format; 59 schools require students to pass this examination for graduation. As of spring 2004, 58 schools will require students in the class of 2005 to pass the new US Medical Licensing Examination Step 2 Clinical Skills examination.
Conclusions The role of the medical school dean has expanded over time and is associated with the creation of a discrete administrative structure for the educational program. The number of full-time medical school faculty continues to increase, whereas the number of enrolled students remains steady. Considerable variability exists among medical schools in their use of standardized clinical evaluations.
INTRODUCTION
In the early years of the 20th century, medical school administration was informal, with the dean's role limited to presiding over faculty meetings and graduation exercises. For example, a sign outside the dean's office at Yale University in 1910 read, "Office Hours, 8:30-9:30 AM Wednesdays."1 The role of the deanship became more structured during the 20th century and the pressures on deans increased as medical schools became more complex.2 The length of time deans hold office has decreased3; this was influenced, in part, by organizational characteristics such as institutional size and finances.4 In a number of institutions, the dean also took on an additional role at the medical center or university level, such as vice president for health affairs or president, provost, or vice president for academic affairs.5 We examine both the current turnover of deans and the roles that deans have assumed beyond that of chief academic officer of the medical school.
A major change that occurred this year was the introduction of an examination that tests clinical skills as part of the US Medical Licensing Examination (USMLE) sequence. The USMLE is required for licensure for all physicians in the United States. Until this year, it has consisted of 3 examinations (steps 1, 2, and 3) that test knowledge and reasoning in a computer-based format. For medical students graduating from Liaison Committee on Medical Education (LCME)–accredited US medical schools in 2005 and for international medical graduates, a new USMLE Step 2 Clinical Skills (USMLE Step 2 CS) examination will be required for licensure. This examination evaluates the student's ability to elicit pertinent historical information from standardized patients, perform focused physical examinations, record a patient note, and develop plans for further evaluation.6 Over the years, we have been reporting on how medical schools are assessing the clinical skills of their students.7 This year, we report on whether schools will require the USMLE Step 2 CS and whether they test students in a similar format.
We also review selected data on the medical school administration and faculty; medical school applicants and students; the medical school curriculum and resources to support the educational program; and student evaluation, especially evaluation of clinical skills. These specific data provide an overview of the current state of US medical education and allow a comparison with previous years.
The data in this report were derived mainly from the 2003-2004 LCME Annual Medical School Questionnaire, which was sent to the deans of all LCME-accredited medical schools and had a 100% response rate. Each completed questionnaire was reviewed on receipt and attempts were made to obtain missing data and to verify responses. Comparative data are presented from the 1993-1994 LCME Annual Medical School Questionnaire,8 which had a 99% response rate, and the 1998-1999 questionnaire, which had a 100% response rate.
Data on medical school applicants were obtained from the Association of American Medical Colleges (AAMC) Section on Student Services. The tenure of deans was determined by examining the listing of deans in previous medical education issues of JAMA5, 8 compared with the list for 2003-2004 derived from the LCME Annual Medical School Questionnaire. The AAMC Directory of American Medical Education for the years 1983-1984, 1993-1994, and 2003-20049 was examined to determine the additional titles of medical school deans.
During the 2003-2004 academic year, there were 126 LCME-accredited US medical schools. As of July 1, 2004, the accreditation of the University of Minnesota School of Medicine, Duluth, will be subsumed under the accreditation of the University of Minnesota School of Medicine, leaving 125 LCME-accredited medical schools (Appendix IA, Table 1). In June 2004, the Northern Ontario Medical School in Canada received initial provisional accreditation. For a list of the 17 accredited Canadian medical schools, see Appendix IB, Table 1.
MEDICAL SCHOOL ADMINISTRATION AND FACULTY
Dean turnover has been occurring at a high rate. Only 41 of 125 deans in office in fall 1999 held the same position in fall 2004. The 10-year retention rate was approximately 10%; 13 of 126 deans in office in 1993-1994 still occupied the deanship in 2004. Many deans also have additional responsibilities at the university or medical center levels. In 2003-2004, 61 deans (48%) held another title, such as vice president or vice chancellor for health affairs, chancellor, provost, or president, compared with 59 deans (47% of total) in 1993-1994 and 41 deans (33%) in 1983-1984 who carried an additional title.
Many medical schools have created a formal administrative structure for the educational program. One hundred four schools (83% of total) reported having a single senior administrator other than the dean with broad responsibilities for medical education. Of these, 19 individuals had responsibility for the undergraduate medical education program only; 3 for undergraduate and graduate medical education; 7 for undergraduate, graduate, and continuing medical education; 30 for undergraduate medical education and student affairs or admissions; 9 for undergraduate and graduate medical education and student affairs or admissions; 31 for undergraduate, graduate, and continuing medical education and student affairs or admissions; and 5 for some other combination of responsibilities. In addition, the administrator for the educational program had responsibility for faculty affairs in 31 schools, for the library in 25 schools, and for information technology in 29 schools.
Department chairs also have had substantial turnover. As of January 1, 2004, 107 medical schools (85%) had 1 or more department chair vacancies. The mean number of vacancies in schools with vacancies was 3 (range, 1-12). During 2003-2004, 108 schools (46%) hired 1 or more department chairs (mean, 2). The number of vacancies and the number of department chairs hired in 2003-2004 are comparable with 1998-1999.
The number of full-time medical school faculty members continues to increase (Table 1). In 2003-2004, there were 114 549 full-time faculty members, a 4.6% increase from the 109 526 faculty members in 2002-2003. There were 20 133 full-time faculty members in basic science departments and 94 416 full-time faculty members in clinical departments during 2003-2004 (Table 2). This represents a 4% increase in basic science faculty and a 4.7% increase in clinical faculty compared with 2002-2003.
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Table 1. Number of Full-time Faculty and Medical Students in US Medical Schools
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Table 2. Full-time Faculty Positions by Discipline and Academic Rank in US Medical Schools, 2003-2004
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The number of full-time medical school faculty has increased during the past 20 years, whereas the number of medical students has remained almost constant. In 1983-1984, there were 56 564 faculty members and 67 443 students, for a faculty-student ratio of 0.84.10 By 1993-1994, the number of faculty had increased to 90 975, whereas the number of students was 66453 (faculty-student ratio, 1.37).8 By 2003-2004, the faculty-student ratio was 1.71.
During 2003-2004, there were 1685 part-time and 5553 volunteer faculty members in basic science departments and 20 199 part-time and 143 668 volunteer faculty members in clinical departments. The total number of faculty members in US medical schools was 285 654, a 3.9% increase from 2002-2003.7
MEDICAL STUDENTS
Applicants and Accepted Applicants
The number of applicants to US medical schools increased to 34 786 for the class entering in 2003 (a 3.5% increase from the number of applicants for 2002). This is the first increase in applicant numbers since 1996 (Table 3). In all, 1161 more individuals applied to medical school in 2003 than in 2002. The number of women applying to medical school in 2003 increased to 17 672 (Table 4), an increase of 1116 women (6.7%) from 2002. Therefore, approximately 96% of the total increase in medical school applicants can be attributed to the increase in applications from women. Of all applicants in 2003, 50.8% were women. This is the first time that women were the majority of US medical school applicants. Of all applicants for the 2003 entering class, 17 539 were accepted. This represents an applicant acceptance ratio of 2.0.
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Table 3. Application Activity During 20-Year Period
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Table 4. Women in US Medical Schools During 20-Year Period
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Enrolled Students
The mean grade point average (GPA) of students entering in 2003 was 3.64, and their mean Medical College Admission Test (MCAT) scores were 9.5 in verbal reasoning, 9.9 in physical sciences, and 10.2 in biological sciences compared with a mean GPA of 3.47 and mean MCAT scores of 9.4 in verbal reasoning, 9.4 in physical sciences, and 9.4 in biological sciences for the class entering in 1993.8 The total number of students enrolled in US medical schools during 2003-2004 was 67 166 (Table 1) and first-year enrollment was 17 118 (Table 3). Of all enrolled students, 32 146 (47.9%) were women (Table 4). In the 2003 entering class, there were 8528 women, which was 49.8% of first-year enrollment (Table 4). Of the 15 996 individuals projected to graduate in 2004, 7343 (45.9%) were women (Table 4).
During 2003-2004, 1003 students (1.5% of total enrollment) were repeating all or part of an academic year. Of these, 419 students were repeating the first year (2.4% of first-year enrollment) and 587 (1.2% of students in years 2-4) were repeating another year. Also, in 2003-2004, 1010 students (1.5% of total enrollment) were on a decompressed schedule (ie, taking fewer courses per year than typical). Of all students on a decompressed schedule, 254 (25%) were in the first year, 265 (26%) were in the second year, 225 (22%) were in the third year, and 266 (26%) were in the fourth year. Reasons for the decompressed schedule were problems with academic preparation or performance (34%), advanced study or academic enrichment (32%), family or personal reasons (22%), and other reasons (13%).
A total of 388 students transferred into LCME-accredited US medical schools in 2003-2004 (0.6% of total enrollment). Of all transfers, 51% came from other LCME-accredited US medical schools, 36% from non–MD degree granting graduate or professional degree programs, 7% from non–LCME-accredited foreign medical schools, 4% from osteopathic medical schools, and 2% from non–LCME-accredited US medical schools.
Medical Student Debt
The debt of graduating medical students continues to increase. Of students graduating in 2003, 83% had debt; of those with debt, the average debt was $109 457.12 This compares with an average educational debt of $85 170 for indebted graduates in 1998.13
To assist medical students with this serious debt load, most medical schools (116 of 126) offer formal counseling on debt management. These educational sessions most typically occur in the first (102 schools) and fourth (115 schools) years but may also be held during years 2 (53 schools) and 3 (50 schools). Medical schools also attempt to reduce debt by supplying scholarship support to medical students. In 2003-2004, an average of 60% of students at schools received some scholarship funding from medical school or university sources.
EDUCATIONAL PROGRAM
Curriculum Structure
During 2003-2004, an average of 38 weeks were required in the first year of the medical curriculum, 36 weeks in year 2, 47 weeks in year 3, and 35 weeks in year 4, for a total of 156 weeks. This is a slight increase from 1993-1994, when an average of 152 weeks were scheduled: 37 in year 1, 35 in year 2, 46 in year 3, and 34 in year 4.8 The average numbers of scheduled curricular hours during 2003-2004 were 830 in year 1 and 763 in year 2. This represents a reduction in total scheduled hours compared with 1993-1994, when there was an average of 876 hours in year 1 and 827 in year 2.8
In 2003-2004, students spent the following mean (mode) numbers of weeks in required clerkships: ambulatory care, 5.6 (4); family medicine, 5.5 (4); internal medicine, 11.6 (12); neurology, 4.4 (4); obstetrics-gynecology, 6.6 (6); pediatrics, 7.2 (8); psychiatry, 6.7 (6); surgery, 8.8 (8); and surgical subspecialties, 4.4 (4). Ambulatory care clerkships occurred in 53 schools, family medicine clerkships in 111 schools, neurology clerkships in 98 schools, and clerkships in 1 or more of the surgical subspecialties in 64 schools. The remaining clerkships mentioned previously were present in all medical schools with 4-year programs.
The average amount of time students spend in the ambulatory setting varies across clerkships: 96% in ambulatory care, 93% in family medicine, 47% in the surgical subspecialties; 44% in pediatrics, 35% in obstetrics-gynecology, 30% in neurology, 28% in psychiatry, 24% in internal medicine, and 20% in surgery. In addition, students in 79 schools (63%) spend time with voluntary faculty in community-based ambulatory settings during the course that teaches basic clinical skills (ie, history taking and physical examination).
Resources for the Educational Program
Many types of resources are necessary to allow medical schools to implement their educational programs. One critical resource is faculty. To ensure that full-time faculty members are available to teach, a number of medical schools are creating mechanisms to explicitly compensate departments or individual faculty members for faculty teaching effort. During 2003-2004, 40 medical schools (32%) had developed a system to assign weight and value to the time faculty devote to educational activities, 38 (30%) had such a system under development, and 48 (38%) had not considered such a system. In addition, 35 schools (28%) had implemented a system to distribute funding to departments or faculty members based on documented faculty educational effort and 40 (32%) were developing such a system, whereas 51 schools (41%) had not.
Community-based (volunteer) faculty who teach in their own offices or clinics or at medical school sites also are a valuable resource for the educational program. During 2003-2004, 48 medical schools (38%) provided monetary payment to some or all of their volunteer faculty members in return for their teaching. Other types of recognition given to volunteer faculty include access to the library and the ability to perform literature searches (117 schools), dinners or certificates of appreciation (106 schools), access to faculty development programs (102 schools), access to free or discounted continuing medical education programs (90 schools), access to athletic facilities or sports events (41 schools), and free or discounted computers or software (39 schools).
Teaching in the community-based ambulatory setting can have a number of associated costs, including student travel and lodging, faculty travel to visit the dispersed sites, and management of the logistics of site identification and student placement. Medical schools use a variety of funding sources to support these experiences, including regular departmental budgets (98 schools), medical school central funds (91 schools), Area Health Education Center funds (52 schools), federal grants (47 schools), grants from state agencies or the state government (29 schools), and grants from private foundations (20 schools).
In-patient clinical teaching sites also are a major resource for medical education. The 126 medical schools used a total of 924 hospitals as major in-patient sites for required clinical clerkships. Fifty-one medical schools used 1 or more university-owned or medical school–owned hospitals; 109 used private, not-for-profit hospitals; 39 used private, for-profit hospitals; 94 used federal (Veterans Affairs or US Department of Defense) hospitals; and 68 used public (state, city, county) hospitals.
With the advent of the new required clinical skills examination part of the USMLE, medical schools have an enhanced incentive to teach and test clinical skills in a standardized manner. There is, however, current variability across schools in the facilities available for these activities (Table 5). Twenty-three percent of schools in 2003-2004 used only existing clinic space that may not be optimally designed for student teaching and evaluation and also may not be consistently available. An additional 8% of schools used space owned by another institution, which also could affect access.
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Table 5. Types and Ownership of Space Used for Teaching and Evaluation of Clinical Skills and Requirement to Pass School SP/OSCE and USMLE Step 2 CS Examinations*
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STUDENT EVALUATION
Evaluation of Knowledge
In 2003-2004, 122 medical schools required students to take and 107 schools required students to pass Step 1 of the USMLE. For the USMLE Step 2 Clinical Knowledge (USMLE Step 2 CK) examination, 120 schools required students to take and 83 required students to pass the examination. Eighty-one schools (66%) required students to pass both the USMLE Step 1 and Step 2 CK. In 1993-1994, 85 schools (67%) required a passing score on Step 1, 54 (43%) required a passing score in Step 2 CK, and 52 (41%) required a passing score on both examinations.8
Almost all medical schools (123 of 126) use 1 or more National Board of Medical Examiners subject examinations to evaluate students' knowledge in courses or clerkships. During 2003-2004, basic science subject tests were used as follows: behavioral sciences (17 schools), biochemistry (31 schools), gross anatomy/embryology (29 schools), histology/cell biology (21 schools), microbiology (32 schools), neuroscience (25 schools), pathology (40 schools), and physiology (29 schools). The subject tests are more commonly used in the clinical disciplines: family medicine (60 schools), medicine (112 schools), obstetrics-gynecology (115 schools), pediatrics (102 schools), psychiatry (106 schools), and surgery (109 schools). The composite basic science examination is used in 30 schools, the composite clinical examination in 7 schools, and the introduction to clinical medicine examination in 25 schools.
Evaluation of Clinical Skills
Implementation of the new USMLE Step 2 CS requires schools to decide whether the results will be used to affect student progress. As of spring 2004, 58 medical schools (46%) had decided to require passage of the examination for 2005 graduates, 56 schools (44%) had decided not to require passage, and 12 schools (10%) had not made a decision on the issue.
Medical schools vary in the extent they use standardized patient/objective structured clinical examinations (SP/OSCEs) to assess student clinical performance. During 2003-2004, 10 schools used a SP/OSCE-type assessment in only 1 clerkship, 16 schools in 2 or more clerkships, 14 schools only as a final comprehensive evaluation outside the required clinical clerkships, 19 schools in 1 clerkship and a final comprehensive evaluation, 61 schools in 2 or more clerkships and a final comprehensive evaluation, and 5 schools in neither a clerkship nor a final comprehensive evaluation. In general, the use of standardized clinical evaluations has increased over time. In 1993-1994, only 38 schools used SP/OSCE-type evaluations in 1 or more clerkships.8
Of the 94 schools that use a SP/OSCE-type examination as a final comprehensive assessment of clinical skills, 59 require passage of the examination for graduation. The number of stations in the final comprehensive SP/OSCE varies across schools: 5 stations or less in 8 schools, 6 to 10 stations in 61 schools, 11 to 15 stations in 20 schools, and 15 or more stations in 15 schools.
In the 94 schools with a final comprehensive SP/OSCE-type examination, there does not appear to be a relationship between schools that require passage of their own examination and schools that require passage of the USMLE Step 2 CS (Table 5). For the 32 schools that do not have a final comprehensive SP/OSCE-type examination, 13 will require passage of the Step 2 CS, 16 will not require passage, and 3 are undecided.
COMMENT
The dean's assumption of additional responsibilities, often in the clinical care arena, has the potential to create a void in the management of the educational program. An administrative structure has emerged at many institutions to fill this gap, with the creation of a position, such as vice dean or senior associate dean for medical education, with broad responsibilities for educational program management. The authority of the position often spans undergraduate, graduate, and continuing medical education. How this affects medical student education is uncertain, but it has the potential to foster a true educational continuum.
The number of medical school faculty members continues to increase in both the basic science and clinical departments. The increase in faculty numbers has occurred in most disciplines, indicating a general, rather than a targeted, expansion. The specific reasons for the expansion have not been studied in depth. The growth in the number of clinical faculty, however, mirrors the increase in the proportion of medical school revenue from faculty practice.14 The development of mechanisms to document and reimburse for faculty teaching effort is a positive step to ensure that faculty are available to teach, in the context of other significant demands on their time.
For the first time since 1996, the number of applicants to medical school has increased. There are no data on why the trend of decreasing applications has reversed, but application activity tends to be cyclical. In the past 30 years, the number of applications increased to 42 624 in 1974-1975, declined to 26 721 in 1988-89, increased to an all-time high of 46 965 in 1996-1997, and then declined until this year.15 Even in the deepest troughs, the number of applicants exceeded the number of positions by approximately 2 to 1, and the academic qualifications of the entering class has continued to increase.
Medical student debt continues to be a significant problem. The amount of scholarship support available across schools is variable and does not, in the national aggregate, mitigate the increase in debt levels. How debt is affecting the choices that students make regarding specialty and practice location is unclear; however, there appears to be some influence. In the 2003 AAMC Medical School Graduation Questionnaire,12 approximately 15% of responding fourth-year medical students reported that debt had a moderate-to-strong influence on their specialty choice.
Compared with 10 years ago, the amount of time that students in the first 2 years of the curriculum spend in scheduled class time has decreased, whereas the total required weeks of instruction has increased slightly. One possibility is that more time is being made available during the day for students to engage in self-directed learning or independent study outside scheduled class time. This would be a positive development, because it fosters habits of lifelong learning important for physicians as they progress through training and into practice.
Medical schools continue to require access to affiliated clinical hospitals and volunteer clinical faculty to meet the needs of the educational program. Less than half of medical schools, or their parent universities, own a teaching hospital. This makes medical schools dependent on affiliated clinical teaching sites that may be vulnerable due to increasing financial pressures in the health care system. There also is ongoing concern about the availability of volunteer clinical faculty, whose need to remain productive clinically may affect their ability to donate time to teaching. More than one third of medical schools currently are paying at least some of their volunteer faculty to teach. Any efforts to acquire adequate funding for medical education should take into account the continued need for valuable clinical and faculty resources that exist outside the academic medical center.
Medical schools vary greatly in the extent to which they use standardized evaluations, such as the SP/OSCE, to assess students' clinical skills. This may be a function of limited resources at some institutions, such as the absence of dedicated facilities for clinical skills teaching and evaluation and lack of funding for a standardized patient program. The results of the new USMLE Step 2 CS may bring the variability among schools into focus. In addition to ensuring that students have mastered basic clinical skills, there will be a need for all schools to familiarize students with the SP/OSCE clinical evaluation format.
AUTHOR INFORMATION
Corresponding Author: Barbara Barzansky, PhD, Division of Undergraduate Medical Education Policy and Standards, American Medical Association, 515 N State St, Chicago, IL 60610 (barbara_barzansky{at}ama-assn.org).
Author Affiliations: Division of Undergraduate Medical Education Policy and Standards (Dr Barzansky) and Division of Graduate Medical Education (Ms Etzel), American Medical Association, Chicago, Ill.
REFERENCES
1. Lippard V. A Half-Century of American Medical Education, 1920-1970. New York, NY: Josiah Macy Jr Foundation; 1974:51.
2. Burrow GN. Tensions within the academic health center. Acad Med. 1993;68:585-587.
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3. Banaszask-Holl J, Greer D. Turnover of deans of medicine during the last five decades. Acad Med. 1994;69:1-7.
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4. Kevin R, Bhak K, Moy E, et al. Organizational, financial, and environmental factors influencing dean's tenure. Acad Med. 1998;73:640-644.
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5. Barzansky B, Jonas H, Etzel S. Educational programs in US medical schools, 1998-1999. JAMA. 1999;282:840-846.
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6. US Medical Licensing Examination. 2004 USMLE Step 2 Clinical Skills Update. Available at: http://www.usmle.org/step2/Step2CS/Step2Indexes/Step2CS2004update.asp. Accessed July 26, 2004.
7. Barzansky B, Etzel S. Educational programs in US medical schools, 2002-2003. JAMA. 2003;290:1190-1196.
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8. Jonas H, Etzel S, Barzansky B. Educational programs in US medical schools, 1993-1994. JAMA. 1994;272:694-701.
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9. Association of American Medical Colleges (AAMC). AAMC Directory of American Medical Education. Washington, DC: Association of American Medical Colleges; 1983-1984, 1993-1994, 2003-2004.
10. Crowley A, Etzel S, Peterson E. Undergraduate medical education. JAMA. 1984;252:1525-1532.
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11. AAMC Data Warehouse: Applicant Matriculant File [database online]. Washington, DC: Association of American Medical Colleges, 2003. Updated November 6, 2003.
12. Association of American Medical Colleges Medical School Graduation Questionnaire, 2003: All Schools Report. Washington, DC: Association of American Medical Colleges; 2003.
13. Association of American Medical Colleges Medical School Graduation Questionnaire: All Schools Report, 1998. Washington, DC: Association of American Medical Colleges; 1998.
14. Krakower JY, Coble T, Williams J, Jones RF. Review of medical school finances, 1998-1999. JAMA. 2000;284:1127-1129.
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15. Association of American Medical Colleges (AAMC). AAMC Databook. Washington, DC: Association of American Medical Colleges; 2002.
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