Terra Sigillata

ResearchBlogging.orgReuters Health Executive Editor and proprietor of the excellent Embargo Watch blog, Ivan Oransky, was kind to alert me to this topical paper that appeared in Monday’s issue of Annals of Internal Medicine entitled, The Social Mission of Medical Education: Ranking the Schools.

To the credit of the Annals, the full text of the primary article is currently free. An accompanying editorial is behind the subscription wall.

The study was conducted led by Fitzhugh Mullan with Candice Chen, MD, Gretchen Kolsky, and Michael Spagnola from the Department of Health Policy at the George Washington University and Stephen Petterson, PhD from The Robert Graham Center was supported with funding from the Josiah Macy Foundation.

The authors developed a metric called “social mission” to rate US medical schools on their responsiveness to three major issues they cite as facing medical schools and policymakers: “an insufficient number of primary care physicians, geographic maldistribution of physicians, and the lack of a representative number of racial and ethnic minorities in medical schools and in practice.”

Attempts to increase physician distribution to underserved populations and/or geographical areas have had mixed success. My anecdotal experience is a typical case: a program to recruit high school students from rural areas to medical schools gave me a chance to work while a postdoc with an exceedingly bright high school student from a sheep ranching family in rural northwestern Colorado. She went to the University of Colorado Medical School and did a vascular surgery fellowship at Emory University, finally returning to Denver. In her case, it’s not just that a country kid got a taste for the big city; she told me long ago that she couldn’t be a doc in her rural town because the one that was there hardly ever got a chance to take a day off or vacation. So – yes – being a vascular surgeon in the city gives her more flexibility than being a primary care physician in the country.

And with all of the baited breath that awaits annual magazine rankings of all educational institutions, this passage in the Introduction notes that such rankings fail to take into account these major issues that impact underserved communities:
“Medical schools, however, are the only institutions in our society that can produce physicians; yet assessments of medical schools, such as the well-known U.S. News & World Report ranking system, often value research funding, school reputation, and student selectivity factors over the actual educational output of each school, particularly regarding the number of graduates who enter primary care, practice in underserved areas, and are underrepresented minorities.”

To evaluate the “social mission” rating of US medical schools, the authors developed a metric based on three criteria: percentage of graduates who become primary care physicians, work in health professional shortage areas (HPSAs) as defined by the Health Resources and Services Administration, and are underrepresented minorities based on an Association of American Medical Colleges (AAMC) definition (African-American, Hispanic, and Native-American).

These criteria were then used to rank medical schools based on following the career path of 60,043 physicians in active practice who graduated during 1999 to 2001 using data from the American Medical Association Masterfile.

The three historically Black medical colleges obviously skewed the data for the underrepresented minority score so the authors, “normalize[d] the skewed distribution, we calculated the standardized scores without these 3 schools, then reincluded them by using the calculated mean value and SD.”

Still, these three schools – Morehouse in Atlanta, Meharry in Nashville, and Howard in Washington, DC – ranked as the top three schools in social mission. Perhaps not surprisingly is that the major top-tier USN&WR medical schools in the northeastern US ranked in the bottom 20 of the rankings, with Duke, Stanford, and Johns Hopkins the bottom three – the only time you will ever see these schools at the bottom of any ranking.

You can view Table 1 for yourself to see if there are any surprises to you. I was pleasantly surprised to see Kansas, Michigan State, Iowa, and Oregon Health & Sciences among the top 20. Conversely, I was surprised to see Texas A&M in the bottom 20.

The key point of my post here, and perhaps the primary reason Ivan Oransky referred the article to me knowing of my interests, is that we see here a specific and essential role of historically Black colleges and universities. HBCUs not only education underrepresented populations, but they then served underrepresented communities – not just with regard to race but also with regard to, in this case, providing primary care to areas with a shortage of health professionals.

Of course, not everyone is happy with a social mission in medicine. The first commenter on the paper, William S. Aronstein, in a screed entitled, Fundamentally Wrongheaded, seems to state that medicine is above this and responsiveness to diverse and underserved populations is more the realm of public health. Beginning with, “This is one of the most disturbing articles I have ever seen in the Annals,” it’s worth a read if for nothing else than this gem taking a swipe at the corresponding author:

To a large degree, I suspect that the folk-marxist ethos in which from his other voluminous writings at least Fitzhugh Mullan appears to operate may account for the article’s emphasis on population-based public health rather than the actual practice of medicine.

Any wagers as to whether he graduated from one of the bottom 20 schools?

Mullan F, Chen C, Petterson S, Kolsky G, & Spagnola M (2010). The social mission of medical education: ranking the schools. Annals of internal medicine, 152 (12), 804-11 PMID: 20547907

Comments

  1. #1 Theodore MS3
    June 18, 2010

    I am a third year medical student at the University of Colorado SOM, so it is very nice to hear you make the reference. Anyway, primary care is at the top of my list of things that I would really enjoy in an ideal world. Though at the moment I am quite worried about the long term potential of such a career. The looming Medicare/Medicaid cuts are perhaps at the forefront of my mind, but even if it wasn’t for the direct pay cuts current reimbrusement models keep whittling away at the time primary care physicians can spend with their patients. The current expectation is for PCP visits to last less than 12 minutes. To really emphasize that point I tried renewing my auto insurance policy and the very polite customer service representive spent more than that asking questions about other vehicles, other drivers, driving habits etc. I find it mindblowing the expectation to manage chronic conditions, diagnose new issues and also spend some time on lifestyle interventions in such a short period of time. Anyway, I just thought I might be a single datapoint and emphasize that my hesitancy to do primary care has less to do with my school and much more to do with the schizophrenic political climate and the popular culture expectation to practice fast food medicine.

  2. #2 Vanessa
    June 23, 2010

    Attention HBCU College Faculty and Administrators:
    Learn how to internationalize your campus through the U.S. State Department-sponsored Fulbright Scholar-in-Residence Program. A special webinar is being offered for U.S Historically Black colleges and Universities. It will include presentations by HBCU college administrators who have hosted SIR grantees. Date and time: June 25, 2010, 2:00 pm to 3:00 pm EDT. Those interested can go to http://www.cies.org/sir/webinars.htm to register.