Fitzhugh Mullan, MD; Candice Chen, MD, MPH; Stephen Petterson, PhD; Gretchen Kolsky, MPH, CHES; Michael Spagnola, BA
This article has been corrected. For original version, click â€œOriginal Version (PDF)â€ in column 2.
The basic purpose of medical schools is to educate physicians to care for the national population. Fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce.
To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions.
Secondary analysis of data from the American Medical Association (AMA) Physician Masterfile and of data on race and ethnicity in medical schools from the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine.
U.S. medical schools.
60Â 043 physicians in active practice who graduated from medical school between 1999 and 2001.
The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score.
The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and nonâ€“community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas.
The AMA Physician Masterfile has limitations, including specialty self-designation by physicians, inconsistencies in reporting work addresses, and delays in information updates. The public good provided by medical schools may include contributions not reflected in the social mission score. The study was not designed to evaluate quality of care provided by medical school graduates.
Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation. These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities.
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Sahil C. Tah
Morehouse School of Medicine
June 15, 2010
Thanks for the interesting article. I look forward to seeing more research done in this area. I just wanted to point out that the name of our medical school is Morehouse School of Medicine, not Morehouse College as listed in Table 1 of the article.
Morehouse School of Medicine is a completely separate institution from Morehouse College, and I feel this should be clarified because many people believe that the school of medicine does not accept female or non- minority students, which is contrary to the fact.
Sahil C. Tah, MD
Chief Resident of Internal Medicine
Morehouse School of Medicine
Peter F. Malet, M.D., FACP
Winthrop University Hospital, Mineola NY
June 17, 2010
Correction in Table 1
At position number 15 in the lowest 20 table, the "University at Albany, State University of New York" is listed. That institution has no medical school. Certainly the authors were referring to Albany Medical College, in Albany NY, where I completed my residency in Internal Medicine.
Albany Medical College is part of Union University. Union College, Union Graduate College, Albany Medical College, Albany Law School, Albany College of Pharmacy, and the Dudley Observatory of the City of Albany are united and known as Union University.
The listing of Albany Medical College is correct in the appendix of the article.
Eric A Mellon
University of Pennsylvania
Research Medical Schools Serve Important Social Mission
When I was eight years old, my father, newly diagnosed with alpha-1- antitrypsin deficiency (A1ATD), underwent his first liver transplant. His diagnosis and treatment underscore the importance of every day advances in medical discovery. In 1989, the DNA mutations underlying A1ATD had only recently been described, liver transplants were considered experimental surgery, and his survival hinged on successful immunosuppression--at the time bolstered by the recent introduction of cyclosporine. It has been over 22 years since we thought he was going to die. He is still alive thanks to the highest specialty care and medical research.
This provided my motivation to pursue MD/PhD training at the school ranked number 129 by the scoring system of Mullen, et al (1). The research performed during that time will, hopefully, soon be utilized towards better diagnosis and detection of disease. My reward is extended residency and fellowship training so I can fight to establish myself as a physician- scientist. For this extensive training, I can expect much lower pay, lower job security, less location flexibility, and increased work-hours compared to private practice. Still, I committed myself to becoming a physician- scientist because I believe in the social mission of medical research.
Through grants and donations, research medical schools graduate many future physician-scientists who will discover new ways to combat disease. This is only a part of the school's overall mission. We provide the highest level of specialty care for a large number of patients who cannot be served elsewhere in the area. In addition, vast amounts of general and uncompensated care are provided for the community.
I believe that I grew up very disadvantaged. I come from a lower middle class background with a mother with severe mental illness and my father with A1ATD and many complications. I lived in mostly African- American neighborhoods and I am a high school dropout. Yet the "social mission ranking" implies that my mission and my diverse background are unimportant and leaves my work uncounted.
That is a pity. Because many of the world's smartest, most driven physicians and physicians-in-training train and work among the longest in medicine for a social mission--the social mission of discovering new cures for disease. It is because of that mission that I had a father to grow up with.
Sincerely, Eric A. Mellon, PhD University of Pennsylvania, Combined Degree Program, MD/PhD Training Year 8
1. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. Ann Intern Med 2010 152:804-811
William S. Aronstein
This is one of the most disturbing articles I have ever seen in the Annals.
First of all, the idea of ranking the nation's medical schools in any way is conceptually flawed. This is an endeavor that ought to be left to the tabloid press, rather than given the imprimatur of a scientific journal.
More importantly, I think that this article profoundly misconstrues the purpose of medical education.
To quote the abstract, "The basic purpose of medical schools is to educate physicians to care for the national population." That statement is somewhat softened in the text itself to read, "Medical schools in the United States serve many functions, but one of their most basic purposes is to educate physicians to care for the national population."
I submit that the "basic purpose" of medical schools is to educate physicians to care for their patients.
Caring for a patient is very different than caring for a population.
I suggest that interested readers refresh their memories of Philip Tumulty's article on the role of the clinician (NEJM 1970;283:20-4), Francis Peabody's article on the care of the patient (JAMA 1927,88;877- 882.)
In order to fulfill the purpose of enabling physicians (and surgeons, inter alia) to care for patients, medical schools have other subsidiary roles, such as the generation of new medical treatments, the elimination of scientific and medical error, and also the promotion of the public health. But those are not their basic and most fundamental purpose.
It is probably impossible for the faculty and staff any one school to fully develop its ability to achieve every purpose in medicine to the highest pitch, and therefore some schools will do better in some areas than other areas. It is therefore not useful to rank schools in the unidimensional way that the authors of this paper have done.
But let me return to their fundamental misconception of the "basic purpose" of a medical school. They betray a fundamental misconception of the nature of medicine and of the responsibilities of physicians and surgeons generally, because they elevate the abstract and derivative notion of the health of the population above the real, concrete work of caring for individual patients. They exalt and reify an idea above the work that doctors actually do.
Public health investigations and public health administration are laudable endeavors, but they are not the basic purpose of medical practice.
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. That "groupism" however also generally infects medical science as a whole, since epidemiological evidence has now come to be considered the only sort of evidence to which physicians should attend. The problem is that epidemiologic evidence, including randomized clinical trials, produces results only regarding entire populations, and can not be translated to the care of individual patients without clinical experience and clinical wisdom.
The fact that the basic purpose of medicine is being forgotten is part of a process that is ending the era of what I will call Oslerian medicine. Some, like Franklin Paine Mall, might have been happy to see that era end much sooner than now. However, I think that the basic experiences of practicing medicine and of being a patient are changing in ways that benefit neither patients nor clinicians.
The practice of medicine is being dumbed down to the level of technical procedures carried out on a "population" by feldschers or "barefoot doctors" at the behest of a State-controlled bureaucracy. The system will work very well for those who wish to tabulate the percentage of patients whose physicians inquire about seat-belt use. It will not work so well for a worried, sick woman whose intermittent fevers and evansecent abdominal discomfort require the full and undivided attention of an experienced and thoughtful clinician.
Norman H. Edelman
Stony Brook University
June 18, 2010
Problems with Social Mission Study
The study is troublesome for several reasons. 1] There are mechanical problems. Table one has two readily apparent errors, The University of Medicine and Dentistry of New Jersey is comprised of three distinctly different medical schools and there is no medical school at SUNY Albany, are there more errors? 2] The cohort used may have been necessary to determine practice choices but it was not necessary to determine diversity of entering classes. My own school made dramatic improvements over the next ten years in this regard and thus is falsely depicted on this score. 3] The underlying assumption is that educators' social responsibility, as perceived at any point in time, supercedes their responsibilty to tell their students the truth. As a medical school dean for almost 18 years I stopped lying to my students about the rewards of adult primary care when it became obvious that they were going to be few compared to specialty care. Perhaps academic physians need to take an oath to Socrates the teacher as well as to Hippocrates the physician.
Gregg S. Meyer
Massachusetts General Hospital and Massachusetts General Physicians Organization
June 20, 2010
Mullan et. al's piece on the social mission of medical education is a provocative one. In other areas of healthcare the creation of league tables, even when the underlying measurement is inaccurate, has led to greater attention to the subject being measured. This surely was the case with this article. Unfortunately the authors did get it very wrong in the case of the Uniformed Services University of the Health Sciences, which it characterized as being among the 20 lowest on their "Social Mission Score." That conclusion obviously ignores the reality of that unique school. Among its attributes is the fact that 100% of its graduates are committed to public service. More importantly the vast majority of their graduates find themselves spending at least part of their professional lives providing care in the most austere environments, ranging from battlefields to remote outposts and refugee camps. This amount of service to the most vulnerable would fit any rational definition of "social mission" yet has been completely been ignored by the authors. The social mission of USUHS is one for which our nation should be proud and to ignore it creates a false impression at best and at worst is frankly disrepectful to those who serve.
Dr. Meyer is a former Colonel in the U. S. Air Force Medical Corps and continues to serve as adjunct faculty at the Uniformed Services University of the Health Sciences
Scott Barnhart, MD, MPH, FACP
University of Washington
June 25, 2010
Teaching Hospital Provision of Care to Un and Under Insured - a Fourth Indicator of Social Mission?
In an era where professionalism in medicine is increasingly promoted, Mullan and colleagues have brought fresh data and perspective to support a more evidence-based dialogue on the mission of medical education. In addition to the outcome measures of primary care, practice in shortage areas and inclusion of underrepresented minorities we offer a 4th indicator for consideration - the proportion of un and under insured patients cared for in the medical school's teaching hospitals. Given the important socializing effects of medical education, teaching students and residents in institutions which make it a priority to serve all patients provides an early anchor point for a key component of professionalism - social justice.
Scott Barnhart, MD, MPH, FACP Professor, Departments of Medicine, Global Health and Environmental and Occupational Health Sciences (Adjunct) University of Washington
James LoGerfo, MD, MPH, FACP Professor, Departments of Medicine, Global Health and Health Services (Adjunct) University of Washington
martin t donohoe
School of Community Health, Portland State University
June 28, 2010
Medical Education and the Social Mission of Medical Schools
Motivating medical students to enter primary care and work in health professional shortage areas requires healing the historical schism between schools of medicine and public health and focusing medical education more on the socioeconomic, cultural, psychological, occupational, and environmental contributors to illness. Health policy, social justice, human rights, environmental health, and reproductive rights are given short shrift(1,2). Despite calls for increased emphasis on global bioethics (3), aside from informed consent and end-of-life care contemporary ethics discourse and training overemphasizes fascinating dilemmas involving expensive technologies (gene therapy, cloning, prenatal genetic diagnosis and treatment, and face transplants), while inadequately addressing public health(1,2). Barriers to social sciences instruction include: lack of perceived relevance for clinical practice; limited curricular time; lack of qualified instructors; a dearth of commitment from deans and department chairs; inadequate funding; and a paucity of role models.
Furthermore, many academic institutions have recently limited clinic slots for un- and under-insured patients, while promoting luxury care clinics for the privileged (usually without cross-subsidizing indigent care), perpetuating a two-tiered system of care and sending the wrong message to trainees, who should be learning to treat all patients equally(4).
Modification of medical schools' affirmative action policies to focus on social class as well as race may improve care for the underserved, since physicians' socio-economic origins correlate with their patterns of service to the disadvantaged(5). Community service, mentored service- learning assignments, and activist-oriented research projects would provide students greater insight into their patients' health and social problems.
Physicians are obliged, because of their privileged status, the public's investment in their training, and their roles as stewards of the public's health, to be politically active and ensure that our leaders provide for the sickest among us. Unfortunately, physicians have lower adjusted voting rates than the general population. When doctors lobby Congress, they focus more on reimbursement and research funding than on access to care, tobacco control, women's rights, violence prevention, and other social justice issues(1).
Physicians also have a responsibility to oppose, individually and collectively, forces contributing to the spread of poverty, including over -consumption; mal-distribution of wealth; the economic, political, legal, and educational marginalization of women; environmental degradation; racism; human rights abuses; and militarization and war.(1,2) This is especially true now, when fewer scientists hold positions of authority than in times past, and when scientific truths are deliberately obfuscated by the well-funded and sophisticated public relations and lobbying campaigns of those with a vested interest in profiting from environmental degradation and the provision of a basic human right like health care.
1. Donohoe MT. Roles and responsibilities of health professionals in confronting the health consequences of environmental degradation and social injustice: education and activism. Monash Bioethics Review, 2008;27(Nos. 1 and 2):65-82. Available at http://phsj.org/wp- content/uploads/2009/01/monash-env-ethics-paper-with-pg-nos.pdf. Accessed 6/29/10.
2. Donohoe MT. Stories and Society: Using Literature to Teach Medical Students about Public Health and Social Justice. International J of the Creative Arts in Interdisciplinary Practice (IJCAIP) 2009 (Issue 8). Available at http://ijcaip.com/archives/IJCAIP-8-Donohoe.html. Accessed 6/29/10.
3. Dwyer J. Teaching global bioethics. Bioethics 2003;17(5-6):432-46.
4. Donohoe MT. Standard vs. luxury care, in Ideological Debates in Family Medicine, S Buetow and T Kenealy, Eds. (New York, Nova Science Publishers, Inc., 2007). Available at http://phsj.org/wp- content/uploads/2008/04/luxury-medical-care-ideological-debates-in-family- medicine.pdf. Accessed 6/29/10.
5. Magnus SA and Mick SS. Medical schools, affirmative action, and the neglected role of social class. American Journal of Public Health, vol. 90, no. 8, 2000, pp. 1197-1201.
Martin Donohoe, MD, FACP
Adjunct Associate Professor, School of Community Health
Portland State University
Chief Science Advisor, Campaign for Safe Foods and
Member, Board of Advisors
Oregon Physicians for Social Responsibility
Senior Physician, Internal Medicine, Kaiser Sunnyside Medical Center
John A. Brockman
American Medical Student Association
July 8, 2010
The Physician-in-Training's Perspective on the Social Mission Score
We applaud Fitzhugh Mullan and colleagues for their innovative study (1) that provides a stark contrast to the dominant U.S. News and World Report rankings. As medical trainees, we hope that the medical community will not only embrace the concept of social mission but actively engage in the development of more robust metrics. This study represents great progress toward improving the quality of medical education in this country - and toward holding medical schools accountable for producing a cohort of physicians capable of addressing the multifaceted needs of our nation's health.
Using Mullan's study as a springboard, the social mission of medical education warrants further discussion. This study excludes any consideration of research - whether basic science, translational or health services - in calculating social mission score. While NIH research funding alone is a poor proxy for social mission, wholesale exclusion of research's contribution to social mission is similarly myopic. Medical school curriculum is also a critical element of social mission. Undergraduate medical education is not a benign process. What and how core medical concepts are presented and taught colors students' perspectives on what it means to be a physician. Even vital aspects of our curriculum in medicine, such as the development of our professional values, are gleaned by simple exposure to other physicians (2). Finally, from lobbying on Capitol Hill to assisting an individual patient in navigating the labyrinth of our health care system, the social mission of medical education ought to incorporate a measure of the advocacy role physicians must embrace in our fragmented health system. A survey of U.S. physicians lends credence to this need to provide training to physicians- in-training, as 90 percent of practicing physicians felt that advocacy was important, yet only one-third of these physicians actually engaged in any activities around advocacy (3).
Recent suggestions of clearer definitions of terms (4), the use of modeling, and the need for further financial support for advocacy should be integrated into Mullan's discussion of a social mission in medicine. As physicians-in-training, we wholeheartedly support better defining the social mission of medicine and its ramifications on our education and look forward to the next iteration of social mission rankings.
1. 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):818-819.
2. Baernstein, A. Oelschlager, A.M. Chang, T.A. Wenrich, M.D. (2009). Learning professionalism: perspective of preclinical medical students. Academic Medicine 84(5): 574-581.
3. Gruen, R.L. Campbell, E.C. Blumenthal, D. (2006). Public roles of U.S. physicians. JAMA 296(20):2467-2475.
4. Earnest, M.A. Wong, S.L. Federico, S.G. (2010). Physician Advocacy: What Is It and How Do We Do It? Academic Medicine 85(1):63-67.
July 12, 2010
I entered medical school with a resolve to plunge into social justice, join Medecins sans Frontieres upon graduating and travel the globe in an effort to eradicate HIV and AIDS. But something unexpected happened during these last four years. I found that I enjoyed studying many areas of medicine. I began to see that my envisioned career was often at odds with every other objective a young person might be expected to have: family, home, stability. I found that my service oriented projects, already strung out by my limited time and flexibility, were largely swallowed whole by the demands of wards and patient care during my third year. If it were just me I might chalk these events up to incompetence, but unfortunately the struggle to incorporate service and humanism practically is one that likely many medical students can relate to.
Many of my friends and colleagues have wrestled with these difficult choices at length in private and in silence, during early morning drives on empty roads, in the depths of night at deserted hospital cafeterias and cafes, individual battlegrounds being contested on behalf of social welfare without recognition or recourse. Medical culture does not leave much room to waiver, and even less to do so publicly, and it can be easy to be overwhelmed by the competing demands of ethics, profession, society and family. We turn to friends, family and faculty for support and encouragement but eventually face the realization that the choices we make cannot be shared, and that the path we choose is ours and ours alone. In that moment some bend under the pressure, realism superseding idealism.
It is likely true that elite medical schools should be and frequently are searching for new avenues to promote and encourage underserved paths for their graduates. The mechanics of these agendas I do not know. What I do know is that in spite of the hurdles, generations of medical students have labored to balance their professional and private lives, personal time against precious minutes with patients. And that ultimately within the artificial decisions of what specialty to pursue, of where to live and practice lies the more meaningful pursuit of true dedication to and passion for our work, courage to stand for what we believe in and to do right, and conviction that the choices borne out of these principles will be vindicated.
George C Hill PhD
Vanderbilt University School of Medicine
July 14, 2010
Commitment and Complexity of the Social Mission of Academic Health Centers
Vanderbilt University School of Medicine (VUSM) considers social responsibility to be a central component of its mission as a university medical center, both locally and nationally. This priority is reflected in broad features of activity, ranging from our research agenda to our clinical and educational enterprises.
One of our commitments during the past decade has been to broadly diversify our medical school class. This effort has provided a new richness to Vanderbilt's medical education programs while greatly expanding the number of minority physicians and physician scientists coming from our school.
Our incoming class is one of the most diverse in the US, with 23 percent of the 105 students from groups underrepresented in medicine (URM). Similarly, 15 percent of the entering class of 111 Ph.D. students are URMs who will one day seek careers in biomedical research.
The efforts are not only producing minority physicians to provide healthcare, but also future medicine and biomedical research leadership who will focus on the pressing questions aimed at the urgent priorities of all members of American society.
One of the important aspects of our research goals is service to our nation. We are engaged in the Southern Community Cohort Study, one of the largest longitudinal epidemiological projects addressing racial and ethnic health disparities, along with partners including Meharry Medical College. Together, over 70,000 individuals, mostly African-American, have been recruited to help us understand the causes of high cancer mortality in African Americans.
Locally, VUSM is committed in numerous ways to the health of our community including those underserved individuals. The Shade Tree student- run health clinic, initiated by our medical students seven years ago, provides needed healthcare for free to our surrounding community. The medical center also provides nearly half of all uncompensated care in Davidson County, with $325 million projected for fiscal year 2010.
The commitment of a university medical center to social responsibility, while important, requires consideration of the broad array of factors that reflect the tremendous complexity of each academic health center's mission and its unique roles locally and nationally.
As Jeff Balser, our Dean and Vice Chancellor for Health Affairs, recently noted, "like our peer institutions, we are compelled, and challenged, to align our strategies and resources in a manner that nourishes our local community, while at the same time addressing the compelling national and international problems in health care. Both priorities are fundamental to fulfilling social responsibility -- a responsibility that Vanderbilt proudly embraces through commitment, innovation and leadership."
George C. Hill, PhD Associate Dean for Diversity in Medical Education Bonnie M. Miller, MD Senior Associate Dean for Health Sciences Education John A. Zic, MD Associate Dean of Admissions Vanderbilt University School of Medicine Nashville TN 37232
George Washington University
August 2, 2010
Discussion of Social Mission of Medical Education Article
We have been gratified by the interest that "The Social Mission of Medical Education: Ranking the Schools"has generated. We recognize the many benefits that medical schools provide, including basic and clinical research as pointed out by Dr. Mellon and clinical services to uninsured patients as pointed out by Dr. Barnhart. Medical schools, however, receive considerable approbation for these activities - including accolades and funding. The social mission, as we've defined it, garners far less recognition or support. We have frankly been surprised by the reactions of some respondents that examining the record of the nation's medical schools in regard to the practice locations, specialty choices and ethnicity of their graduates is somehow unfair or devalues their school or their career choices.
We acknowledge concerns raised about the lack of inclusion of curriculums of public health and ethics (Dr. Donohoe) and professional values and advocacy (Dr. Brockman). These are extremely important in developing attitudes and skill sets that contribute to an environment where the social mission of education is valued. Dr. Meyer's admonition that the Uniformed Services University of the Health Sciences score was not reflective of the school's service to the nation is well taken. The measures used and the point of measurement of this study did not capture the career dedication to the military mission of the graduates of USUHS.
While one can appreciate Dr. Edelman's many contributory years as a medical educator, one would hope that his grim view of primary care would not become the policy of his faculty, particularly in light of the struggle between idealism and realism experienced by many young people in medicine as described by Dr. Deng. We also note that several hundred thousand American physicians work in primary care and in shortage areas today and while they are not as numerous as needed, most of these physicians have satisfying careers and live financially comfortable lives.
We also recognize that the challenge (personal and institutional) of the social mission of medical education is not limited to the medical school years and that change needs to occur concurrently in all aspects of medical education from admissions through graduate medical education and in practice organization and reimbursement. The Patient Protection and Affordable Care Act takes initial steps to address some of these issues and our study brings focus to the role of medical schools within this overarching effort to construct a system that provides equitable health care for the nation.
Finally, this study is only a single step in examining the social mission of medical education. As many have pointed out, there are additional factors that need to be examined and correlated with social mission outcomes and updates need to be done to evaluate ongoing medical school efforts to address the social mission of medical education.
Fitzhugh Mullan, MD Candice Chen, MD, MPH
Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med. 2010;152:804–811. doi: 10.7326/0003-4819-152-12-201006150-00009
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Published: Ann Intern Med. 2010;152(12):804-811.
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