DIFFICULT CHOICES IN MEDICAL STUDENT EDUCATION

Medical student education faces major fiscal and organizational challenges, and departments must make difficult choices in the near future. Departments of family medicine have 2 student educational mandates. One is the general education of all medical students. The second mandate is family-medicine–specific education with the ultimate aim to increase students’ interest in and selection of family medicine and primary care as career choices.

Many medical student education programs rely on teaching by volunteer faculty, extramural support, and direct or indirect departmental cross-subsidies. Competition for community teaching sites is increasing, requiring more effort, innovative partnerships, and more funding to continue clinical education in the community. Even as the complexity of family medicine clinical teaching is increasing, the resources to do so are decreasing with the current and anticipated decreases in Title VII funding and the inadequate support from many medical schools for the teaching mission in general and primary care in particular. Given these very difficult circumstances, how should we proceed?

A clear view of the fiscal problems enhances our ability to proceed effectively. Our educational centerpiece, the family medicine clerkship, is costly and complex to manage. The cost of a family medicine clerkship ranges from $143,850 to $406,950 per year for 150 students (depending on level of preceptor reimbursement).¹ These costs will grow if the number of medical students increases 15% to 30% as called for by the Association of American Medical Colleges. Furthermore, fueled by Title VII programs support and our specialty’s concern with the production of family medicine and other primary care physicians, we have spent many years developing creative curricula for all levels of learners. The presence of these extramural funds in the form of Title VII has allowed some departments/schools of medicine to forgo full budgeting for these initiatives.^2,3 These estimates do not include the cost of directors of these programs and faculty participation in other courses and committees on campus. The core mission of student education requires career family medicine educators supported with time necessary for program management and the search for new resources needed to sustain and advance this enterprise.⁴

Our first task is to raise new sources of revenue to support new programs and to fund innovations. While doing so, however, we must consider the priority of medical student programs compared with residency education, clinical programs, and research programs. ADFM believes that medical student education is a core mission of departments, and finding new sources of revenue to support it must be a priority. Medical student programs are an essential part of the future family medicine.

We will also need to review critically the components of our predoctoral programs and prioritize those components. How do we choose between these educational components? We believe that there should be a number of guiding principles: First, we must preserve a balance between general student education and education targeted for students with existing and potential interest in family medicine and primary care. We must do both, despite the concerns within the family medicine community that we focus only on producing future family physicians. Second, we must stress educational excellence. ADFM believes that we are always better served with less curriculum of higher quality than more curriculum of mediocre quality. Finally, we must explicitly consider cost effectiveness. Each department has its own setting and context within which the positive impact of specific curricula needs to be weighed against the cost in dollars and time.

What are the choices? How much effort and cost should go to clerkships and their preceptors, compared with preclinical courses? How decentralized should our teaching programs be? How valuable are “pipeline initiatives”, FMIGs, and summer research electives? What should our involvement be in efforts to develop new interdisciplinary curriculum in the third and fourth year? How much emphasis on rural or underserved should there be?^4,5 And what about the need to conduct integrated teaching with basic scientists regarding clinical translation of new research findings? How much innovation can we really afford, especially when we’re paying for most of it?

There will be dramatic changes in the landscape of departments of family medicine which will require a reaffirmation of student education as a core mission associated with new strategies to achieve the ultimate goal to insure quality training for all medical students, especially those who will eventually choose family medicine or other primary care specialties as careers. This may require dramatic redistribution of limited departmental/school resources and curriculum modification while greater support from public and private stakeholders is identified. ADFM is examining the many issues and asking these pertinent questions with the aim of coming to some consensus on how departments should prioritize predoctoral education efforts during these lean economic times.

• © 2006 Annals of Family Medicine, Inc.