This week, FiercePracticeManagement reported on a study published in the Annals of Internal Medicine that raised quite a few eyebrows with regards to medical school rankings. The study looked at things from a "social mission" point of view, essentially ranking the nation's 141 medical schools by how well they produced graduates who practiced primary care, worked in areas with a federally designated shortage of health professionals and belonged to underrepresented minority groups. While some relatively unknown schools like Morehouse College, Meharry Medical College and Howard University topped the list, traditionally high-ranking med schools like Harvard, Stanford and Johns Hopkins were ranked much lower.
Dr. Candice Chen, one of the authors and an investigator at the George Washington University School of Public Health and Health Services, talked to FierceHealthcare about the study, and why she thinks it's important to also look closely at experience and intangibles when it comes to our doctors, as opposed to just test scores.
FierceHealthcare: In the paper, you specifically discuss medical school rankings (like the one created by U.S. News & World Report) and their flaws. What do you think can be done to address these flaws, especially considering that you constantly see schools like Johns Hopkins and Duke atop most medical school rankings, but on your list they rank near the bottom of the pack?
Candice Chen: The interesting thing about U.S. News & World Report is that they do two different ranking systems right now. They've been doing their primary-care rankings now for a good decade-plus. Prior to adding the primary-care ranking, they really valued research, and in their main ranking they still do that. So there's always a question of "what do we value in our medical schools?" It's not that we shouldn't value research and the research that they've produced, but sometimes I think we value research in the absence of valuing some of the things that are looked at in our paper.
Some of it is the components of what we're looking at and what we're using to create our composite score. I think the thing that makes our paper unique compared to, say, the U.S. News & World Report primary-care ranking, is the way we looked at it. The way we looked at it also adds some limitations to our paper, but we're actually looking at outcomes. So we're looking to see after graduates go through residency, go through training, go through their service applications--where do they end up? Are they actually going to be primary-care doctors? Are they actually going to be practicing in underserved areas?
The way [U.S. News] does it is they look at the initial residency, and so as soon as a student graduates from a certain medical school, what residency are they going into? I think most people are going to realize that if you go into family medicine residency, you're most likely going to end up as a primary-care doc. But if you go into, say, an internal medicine residency, you're most likely not going to end up as a primary care doctor with the career choices and the trends we've been seeing over the last decade. While we appreciate that U.S. News & World Report has started to do the primary-care rankings, we also recognize that it's not a true reflection of primary care.
FH: Why do you think there is such a discrepancy with schools in the Northeast ranking poorly? Is it, in fact, because schools there are more research based? Is it because there are more private schools in that region?
CC: The fact is that we looked at--and we kind of broke it out into--how urban is the primary campus? Is the campus private or public? What's the research dollars issue? It's absolutely true, the Northeast schools tend to be more urban. They tend to be more private and they tend to be more highly research funded. All of those factors are cumulative.
You look at New York City, and it's awfully hard to imagine somebody who trained there ending up in rural Ohio or something like that....Our TV shows aren't "Northern Exposure" anymore, they're "Grey's Anatomy".
The interesting thing about that is not to say that we should dismantle those schools, but some schools have been very thoughtful about setting up regional campuses and saying "OK, we recognize that we're located in kind of the biggest city in the state, but we want to expose our students to more primary care community medicine."
Another big [and similar] issue that we're seeing right now is an expansion of medical schools that we haven't seen in about 30 or 40 years. There's a real question of where should we be putting our new medical schools. In Pennsylvania, actually, one of the new medical schools is coming up in Scranton rather than placing another one up in Philadelphia. It's about making smart decisions like that.
FH: What do you think current efforts like the one at Texas Tech to improve primary care numbers, where they're going to a three-year model and cutting the costs?
CC: We think it's fantastic. Part of doing the paper is to bring some attention to these issues. To bring attention to the primary-care issue, the rural and urban, underserved issues and the diversity issues--to encourage individual medical schools to look at themselves and look at where they have strengths and weaknesses and how they can address their weaknesses. The nice thing is is that there are schools out there doing it right now. The new medical schools that are coming on, some are being very thoughtful about setting out social mission strategies before they even open. The Commonwealth Medical College [the new med school in Scranton] has been very thoughtful about setting up a pipeline program to try to recruit and bring local, more socioeconomic students into the school, about setting up their primary-care curriculum and about partnering with regional campuses to increase exposure for students during the four years.
FH: So do you think that recruitment is a bigger issue? How would you say [monetary] rewards for primary-care doctors factor into the equation?
CC: [Salary] is definitely a factor, and a large factor in whether people will go into primary care or not. I think the interesting thing is that when we look at healthcare reform there's a recognition of that, and there's some efforts to increase primary-care payments, to support primary-care practices.
But medical schools have to play their role, too. They have to maximize those changes. And medical schools can make a difference. They can make a difference in terms of their recruitment and admissions practices. They can make a difference in terms of their curriculum. And just in the very culture that they support. Unfortunately, there are schools out there that have no family medicine department, and it's hard to imagine that a student is going to pick family medicine when they're not being exposed to a family medicine department within the school. There are definitely things that schools can do, and we look at it as things have to happen across the continuum. They have to happen through primary education and social equity, in general, through medical education through residency training, through practice and payment reform. But we can't maximize the system. We can't maximize our workforce, build that primary care base, increase access in underserved areas and increase diversity without doing it at all levels.
FH: Would you say that addressing the minority shortage is tougher than addressing the primary-care shortage, and if so, why? Also, what would be the best approach to addressing the lack of minorities?
CC: I think each area has its own challenges. When it comes to diversity, I think it's a question of "what factors do we really want in our graduates?" Is it really a high GPA and a high MCAT score that is going to predict how compassionate or how good of a physician you get on the other side? Or is it the fact that they have a track record of community service?
FH: So you're suggesting taking a harder look at the intangibles over raw numbers (like test scores)?
CC: Exactly. And the nice thing is that all of these issues, I think there's more and more evidence coming out. Obviously we want the intelligent, we want the students that can handle the science of medicine. But we also really do want those students who can connect with their patients and be compassionate. Who can build the patient-provider relationship and do coordinated care and work in teams and do all those things to maximize patient satisfaction and patient quality. It's a balance of, how important really are GPA and MCAT scores and a high-science background versus Peace Corps experience, or something like that.
FH: So how vital do you think addressing the social mission issue is with medical schools?
CC: I think it's something that absolutely needs to be addressed. When we look at healthcare reform, it seems like every week if you get online and do a Google search for "primary-care shortages" or "access to healthcare," it's in the public's interest right now. And with healthcare reform passing, it's becoming a pressing issue because if we're going to increase coverage, many people have realized that insurance coverage doesn't necessarily equal access. So the next question is, how are we going to increase access? Primary care is almost always the first point of access, and the most efficient first point of access for healthcare. If we don't have enough primary-care doctors, coverage may not equal access and we could overrun our emergency rooms even more than we currently do now.
Thinking about our healthcare system, overall, I think these issues are extremely pressing. So therefore, it makes it extremely pressing for medical schools to really address the issue.
FH: So basically you're saying that putting effort into these efforts could have a domino effect and, in the long-run, help alleviate some of those overarching medical costs?
CC: I think, again, when you look at the healthcare reform legislation and you look at how much of it is focused on preventative medicine, preventative medicine is very primary-care medicine. It's not like we're saying to medical schools "stop producing the high technology cancer cures" or things like that. But if we can build our primary-care base, then hopefully we can catch cancers before [patients] necessarily need those high technologies and highly expensive treatments. The goal is always a healthier population and a healthier community.