Accreditation results in movements away from basic health access in multiple dimensions. Board score focus often leads to ever more exclusive in admission. Financial solvency demands departures from primary care focus and focus on grants, research, and specialty services. More and more family medicine departments are falling prey to debt. Medical education is taught by the generalists that interact best with students. Family physicians are 2 times more likely to be found as medical teachers in the Masterfile even with lowest percentages found in medical school zip codes. Generalists at the University of Minnesota in each department were the ones terminated in attempts for solvency and attempts to maintain accreditation. The more specialized faculty generate higher revenues in the RBRVS system. The more general faculty are expendable due to revenue generation and the demands of accreditation. To keep residency training accredited and capture GME funding, the most specialized faculty must be retained.
The entire design reinforced by accreditation results in difficulties for the most needed health access careers.
Family medicine residency programs locations are three times more likely to be found outside of top concentrations of physicians where workforce is most needed, but the percentage is so low already that a tripling is a small result.
Accreditation has also resulted in loss of most needed health access. Some of the best models such as accelerated family medicine residency training have been terminated
Accreditation can make it very difficult for medical schools to facilitate physician distribution by different admissions, different training, or a different location of training outside of major medical centers. At the Rural America: A Challenge for Medical Education, AAMC Conference 1990 in San Antonio there were proposals for reforms that have not been addressed. The same reforms were proposed 13 years previously. It is safe to say that the US could go another 25 years without progress in most needed health access. Devastations are seen across rural workforce, underserved workforce, and primary care. The Standard Primary Care Year - A Required Measuring Tool for Reasonable Comparisons of Primary Care Including Rural and Underserved Primary Care
The first and major pages of LCME documents involve performance on scores and failure rates. Little emphasis is placed on the types of physician graduates or where they location. Increased scores mean decreased distribution and primary care.
It would be helpful if accrediting bodies such as LCME and ACGME understood the 10,000 square mile classroom envisioned by Jack Verby for the RPAP program in Minnesota?
What if LCME And ACGME understood that Preceptorships Are Better Medical Education, especially for rural practice preparation.
Do accreditors understand the impressive evaluations of the RPAP programs, not just where the graduates chose to go but what they did academically? the fact that they were average or below average in their class and moved up significantly? the fact that they equalled or exceeded their classmates in 23 different cognitive, behavioral, and procedural matters?
Do they understand how rare it is for academic medical centers to truly embrace the underserved? Butler Promotes Accountability They did note that Florida State had a unique mission, but they certainly did not allow for this during their evaluations. Also why should Florida State be unique in pursuit of doctors for rural, minority, and geriatric populations. The fact of the matter is that the medical schools in Florida resisted state efforts to improve geriatric training and graduation of geriatricians, even when they were given the money to do so! This resulted in a medical school (other than Nova) that would attempt to meet the needs of the state.
Do accrediting bodies realize the role that they could play to stimulate medical schools to pay attention to the missions that they are supposed to be emphasizing? Do they understand that local, state, and federal dollars are important? Do they realize that there is a reason that presidential administrations zero out Title VII each year and it has to do with failure to be identified as a significant contributor to care of the underserved?
There are exceptions in medical education, schools, departments, and programs that truly make a difference. It has been my privilege to be a part of the Department of Family Medicine at the University of Nebraska Medical Center. I assure you that I was mostly an observer and a historian as I have watched the department's efforts over the past ten years. Even before I came, the Department was on course to winning the National Rural Health Association Program of the year award for 2002. There were two major reasons:
1. Some 15 years ago visionary deans connected our academic medical center to rural communities through two programs, a hub and spoke two way communication and a special rural admissions program that involved a rural track but even more so an approach to choose students from rural Nebraska who were dedicated to service, medicine, and rural communities. This allowed the department to develop all of the graduate programs to help them along this path.
2. Our department embraced the concept of working to meet state needs and, together with the medical school, devoted significant resources to meet these needs. This is a costly process, with close to a third of the budget involved in rural and inner city missions, but it pays big dividends for the state, particularly in physicians locating in rural areas.
By the numbers: Rural Doctors and Rural Economies
Breeding Young Professionals and Healthier Rural Communities
As an observer I have certainly been impressed how much effort it takes to combine admissions, medical education, graduate programs, leadership, and cooperation with state efforts. However we were able to do this with few federal dollars and no AHEC. Why does medical education resist caring for the underserved, rural and urban?
Why does the government, and its accrediting bodies, continue to allow medical schools to avoid meeting national needs?
One of the major problems is a devotion to infrastructure, rather than mission. This is a distortion of Flexner's initial concepts. Flexner’s Impact on American Medicine
Flexner considered 5 areas when he did his visits in 1909 - 1910. It seems that medical education has continued to assess these areas regardless of how we have changed in the past 100 years.
| Flexner 5 criteria | My Critique |
| 1. School entrance requirements | This can make it difficult for the right students, the ones likely to return to underserved areas. Often education and lack of health career orientation in underserved areas is a major obstacles. Lack of adequate numbers should never be a problem because medical schools can always stimulate improvements in high schools and colleges, just as they did in Flexner's day and for the entire nation. |
| 2. Size and training of faculty | All medical schools have moved more and more into community-based faculty and facilities. One hundred years ago when some medical schools had virtually no faculty or equipment or buildings, this was a concern. Now a greater concern is whether faculty actually let students see and care for patients. Those training as physicians need to be able to make decisions. Why a Preceptorship Is Better |
| 3. Sum available from endowment and fees and budget | Financial viability is important, particularly for those with large numbers of buildings and complicated relationships with states, cities, business enterprises, etc. Smaller schools focused on education with reasonably steady sources of funds should not be inhibited by such requirements however. Even closures of medical schools have not stopped medical students from finishing their education.
If the school keeps to its mission of serving the underserved, state and federal dollars should continue to be available. Only if accrediting bodies truly enforced this mission on all schools (and ended shortage areas and maldistribution) would single schools be at risk of not being able to be funded. The fact is that the large schools with large endowments and federal research dollars have been distracted away from missions to serve the underserved. |
| 4. Quality and adequacy of labs and qualifications and training of lab teachers | These are important, but is the emphasis on basic sciences and their impact on other areas such as admissions, emphasizing scores and performance rather than mission, causing a problem. Why do some of the smaller branch campus medical schools prefer leaders from this area with grant and research skills rather than choosing leadership that embraces the needs of the state, particularly for primary care physicians? |
| 5. Relationships between the school and its associated hospitals | Again in the past, the lack of clinical facilities was a problem. Now a bigger problem is finding faculty and facilities that will treat students and residents 1) as mature, adult learners needing to be able to make decisions, 2) with respect. Mostly discussions between schools and hospitals involve federal dollars instead of education. |
| First column from Hiatt MD Around the Continent in 180 Days: The controversial journey of Abraham Flexner, The Pharos, Winter 1999 p 18 - 24 | |
Accrediting bodies need to do no harm, at least to students and rural communities, in their sometimes overzealous pursuit of "quality" in medical education.
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