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Expanding Excellence

UMass Medical School takes a new step to face the physician workforce shortage

By Andrea L. Badrigian

Fall/Winter 2008 Vitae: The Magazine of the University of Massachusetts Medial School

During the fall of 2008, 59 women and 55 men entered the first-year class at UMass Medical School. Fourteen members of the class are first-generation college students, representing their families in graduate-level higher education for the first time. Students are undergraduates from schools including Boston College, Cornell, Georgetown, Harvard and UMass, and the class’s average GPA is 3.65. They are socially and professionally as strong as they are academically; they have been music teachers, Peace Corps volunteers, hospice interns, camp counselors. One is a paralegal, one an Iraq war veteran.

For fun, they love to ballroom dance, play the Scottish fiddle, write songs, act and compete in ultimate Frisbee. The students in the Class of 2012 are much like members of previous School of Medicine classes—just as accomplished and just as committed to being the best physicians they can be.

The difference this year is that there are more of them. Eleven more, in fact, and there will be even more in the fall of 2009, when the entering class size is expected to reach 125, up from 103 in 2007. Such an increase brings both opportunities and challenges for UMMS leaders, faculty and staff. More students in classrooms, clerkships and clinics create impacts on costs and curricula that are still being quantified by planning teams.

UMMS has mobilized over the last several months to respond immediately to the needs of this year’s entering class and to plan for those needs when expansion continues in the years ahead. The institution is doing so against the backdrop of national and state trends that go directly to the issues of access and delivery of health care services to millions of Americans.

In Massachusetts, the Health Care Reform Plan of April 2006 dramatically reduced the number of uninsured residents in the state, bringing more than 300,000 people into the health care system. But the demand for primary care physicians has increased as a result, with the existing supply of practitioners in the state straining to keep up. Meanwhile, the nation’s population has grown by more than 40 million since 1980 and life spans of Americans continue to increase, creating need for more complex and longer lengths of stay for hospitalized patients.

At UMMS, a strategic planning initiative this year with clinical partner UMass Memorial Health Care brought to the fore the unique position the institutions hold in helping to build the physician workforce that will meet the needs of the commonwealth. A law Governor Deval Patrick signed in August will help UMMS in its proactive response by providing greater tuition incentives for students who agree to practice primary care in the state for four years.

So now, UMMS joins medical schools across the United States as they undergo the largest expansion in 40 years. In 2006, 93 of 7 the nation’s 125 medical schools (there are now 129) reported an existing or expected increase in first-year enrollment over 2002 levels. Overall, medical student enrollment is expected to increase by at least 20 percent from 2002 to 2013, with most of that increase coming from expansion of class size. And as schools admit more students they must also build the necessary staff and services to assist them.

Physically Fit

UMMS must report its plans for expansion to its accrediting body, the Liaison Committee on Medical Education (LCME). In its September 2008 report, UMMS detailed impacts of the class size increase from 103 to 114 on educational space and facilities; instructional staff, such as faculty and residents; clinical facilities and patient volume for required clerkships and electives; capacity of student services such as student affairs and financial aid; and the depth of the applicant pool. The report assures the LCME that UMMS is balancing student enrollment with the total resources of the institution; a substantial imbalance in student enrollment relative to resources, the LCME states, may have a negative impact on educational program quality.

Assistant Vice Chancellor for Administration Paulette Goeden is a member of the UMMS team that prepared the LCME report on the class size expansion this fall. “My role was to go through all the data I received from the curriculum and clerkship directors as well as facilities, the library, registrar and financial aid concerning their needs and then put together a formula on the cost to the institution as a result of the class size increase.”

Goeden said that resources are in place to accommodate the expansion of this year’s entering class, while maintaining the quality, depth and richness of UMMS educational programs. This year’s modest expansion will not call for substantial new resources, with departments absorbing minimal costs and already available institutional funds covering others.

“I think everyone really stepped up to the plate and was enthusiastic about the increase, but faculty and departments had legitimate concerns that we are addressing,” she said. “In some of the first-year courses, Anatomy, for example, we want to make sure there are adequate faculty members in labs who can address student questions. Other areas concern financial aid, and the institution has agreed to increase aid available to students.”

Goeden described areas where administrative staff increases are called for this year. “There is a constant accreditation process when it comes to graduate students, including those in medical school. The Registrar’s Office must process daily licensing forms and provide additional supporting documents such as transcripts, certified copies of diplomas and Medical School Performance Evaluations to various institutions and agencies.

We determined that the volume of work for the offices of the registrar and financial aid would increase and approved a position to be shared between the two.”

Classroom spaces for first-year students were assessed and firstyear classes moved to a larger amphitheater so that medical, nursing and biomedical sciences students who attend together can be comfortably accommodated. Breakout rooms and study spaces that reflect the current trend in medical education for small group learning have room reservation priority.

Several existing facilities are being modified for next year’s expected larger class, and the state has committed capital funds—$3.68 million—for renovations and upgrades to lecture halls, small group teaching rooms, amphitheaters and other spaces that support education and the needs of students, according to Mark Armington, associate director of the Facilities Engineering and Construction Department.

Areas being considered for technology/AV upgrades are student-dedicated independent study spaces and the Anatomy and Pathology Teaching Labs. All changes are based on input from faculty and students and studies of how other leading medical schools are conducting their expansion work. “We’re accomplishing this within existing space and if we can learn from similar institutions, we can use some established methods while still responding to our unique needs,” said Armington.

Reflecting on these short-term measures, he added, “Paulette Goeden’s group has no easy task—space is tight and all departments are working together to share the space we have.”

Goeden looks down the road and notes, “As we go larger we are going to have to address space issues.” Perhaps that space will be found in the Albert Sherman Center slated for groundbreaking in 2009 and completion in 2012. The space committee is actively discussing what programs will be located there, and teaching and student space is a high priority, Goeden said.

The Expansion of Diversity

Dean of the School of Medicine Terence R. Flotte, MD, has been in the thick of the strategic planning process, with a keen eye on the goal of designing the workforces of the future in medicine and the health sciences. “The preponderance of data and the official position of the Association of American Medical Colleges is that there is going to be a substantial shortage in this country, and we will not be immune from that,” said Dr. Flotte, who also serves as provost and executive deputy chancellor. “We are reaffirming our commitment to train the primary care workforce in Massachusetts, but in a broader sense, we are being responsive to the health care needs of people of this state, and in this area, I put a finer point on it than some.”

Flotte explained that currently for adults, the physician shortage revolves around generalist care, while for children, subspecialties are in particular demand. “We need to be certain that the way we develop the expanded enrollment meets a variety of goals and objectives.”

Along with these nuances in health care needs, Flotte is emphasizing the opportunity the expansion offers for increased diversity in the student population. Here again, there are distinctions. “We will define that diversity to meet the needs of the state,” said Flotte. “Up until now, the diversity reporting generally to LCME has been students underrepresented in medicine nationally. Now, each school is allowed to define what its diversity goals are, and there are groups in Massachusetts not in the definition that we feel we need to be responsive to.”

He noted that Southeast Asian populations are not considered underrepresented in medicine nationally, yet they represent an important population in Massachusetts. Other recent first-generation immigrants to the state are not in the definition either. “The expansion allows us to have more flexibility” in recruiting students who reflect those populations. Flotte said that the diversity effort must tap into the other UMass campuses. He noted that data on students from underrepresented groups who entered UMMS in 2007 showed that ten came from UMass undergraduate programs. UMass Boston, for example, is quite diverse, with close to 40 percent students of color on campus, according to Flotte.

“The other campuses have lower percentages, but we’ve been in detailed discussions with the provosts about how to channel these students here in a better way.” He also noted the long-standing success of the Worcester Pipeline Collaborative, the outreach initiative started more than ten years ago by UMMS and community partners to develop interest by Worcester school children in careers in health care. “We will continue to support its existing programs and reach out in even more active ways,” said Flotte.

The challenge UMMS faces is that it must admit students who are Massachusetts residents (unless they are MD/PhD students, who may be residents of any state). “The population of students who graduate from Massachusetts high schools who meet the residency requirement, who are underrepresented, and who are now at the stage of applying to medical school is just 50-60 each year. That’s for the whole state,” said Flotte. In most years, almost all of those students apply to UMMS, but many apply to other schools as well, and highly qualified students of color are sought after.

No matter what the background of the student, this year’s class size expansion did not deplete the applicant pool, nor will the anticipated increase next year to 125 students and a potential 30 percent increase overall in the class size, according to Dean of Admissions John A. Paraskos, MD, and Karen J. Lawton, director of Admissions. Each year their office receives 600-800 applications. “Every year we are turning away people with excellent credentials,” said Dr. Paraskos.

On the Ground, In the Clinic

The Office of Student Affairs provides a range of services for medical students throughout their four years at UMMS, from helping students form organizations to advising them on their academic and career paths. Another vital responsibility is helping to assign students to clerkships in their third year, according to Associate Dean for Student Affairs Mai-Lan Rogoff, MD.

 

“Our challenge will be to manage the fluctuation in the third-year class size that typically occurs as a result of the flexibility we offer our students upon completing their second year,” said Dr. Rogoff. Each year, a number of students leave the ranks to take advantage of educational enrichment opportunities, such as research or international service programs or enrollment in a master’s in public health program. Still other students may take a leave to start their families. Since these students don’t all come back at the same time, planning must be done to anticipate the impact of the fluctuation on the third-year class size. Rogoff and her staff are working to ensure a high level of support for students who will need advising, career guidance and residency application services in their third and fourth years.

One of the clerkship directors who Rogoff works with to place third-year students is Frank J. Domino, MD, associate professor of Family Medicine & Community Health. He explained that during the six-week Family Medicine clerkship, students spend four days a week at their community preceptor’s office. There, students typically arrive at ambulatory clinic settings at 8:30 a.m. and see patients with community-based preceptors until 5 p.m.

With a sufficient number of preceptors, the clerkship rotation works well and is evaluated positively by students. But Dr. Domino sees challenges ahead with the class expansion. “We are hearing increasingly that the community doctor has less time to discuss cases with students,” said Domino, who cites the growing patient load primary care physicians are taking on as the reason. “Increasing the class size is a fabulous idea and the goals are wonderful, but I’m concerned we will be asking our community preceptors to take on more students when their time and reimbursement are both severely lacking. Working with a rushed and stressed preceptor will likely make the student experience less valuable,” Domino said.

Along with other clerkship directors, he is working with the expansion planning team to recruit new community-based preceptors, building upon a large and well-developed pool of community-based faculty.

Domino and his colleagues in the department will recruit through outreach to family medicine physicians who move to Massachusetts and at conferences such as those hosted by the Massachusetts Academy of Family Medicine. They also look to UMMS alumni and UMass Memorial Health Care member and affiliate hospitals as well as hospitals outside the system to offer clinical teaching opportunities.

Domino added that as the state has made a commitment to increasing the class size at UMMS, it is critical that a commitment also be made to increasing the attractiveness of practicing primary care in the commonwealth. “Strategies could include developing a universal billing system or improving the reimbursement structure, so a community-based primary care physician who is teaching our students need only see 16 patients per day rather than 22 to be adequately compensated. I would like to tell them: ‘if you take a student, you can see even fewer patients so you have time to teach the learner.’”

Dean Flotte agrees that the biggest challenge presented by the class size expansion is developing additional teaching sites for clinical rotations in the third and fourth years, particularly the third year and particularly when the class size reaches the planned level of 125. “Bringing on a new clinical teaching site is complicated,” he said, but he added that UMMS has an important opportunity through the increase to enhance clinical experiences around primary care. “We’ve been thinking of some additional sites that might provide more of a community hospital kind of feel to the experience and some innovative ways to structure those experiences to make them more longitudinal. How those sites are developed and how much primary care flavor they have, that is the major task yet to be solved. It will have the most added value, though.”

Prime candidates, after adding sites at the UMass Memorial Medical Center University and Memorial campuses, include other member hospitals such as HealthAlliance Hospital in Leominster/Fitchburg and Marlborough Hospital. Rotations in ambulatory clerkships such as family medicine, as well as inpatient rotations in medicine, ob/gyn and surgery, have great potential there. Expansion at other educational affiliates, such as Milford Regional Medical Center, Saint Vincent Hospital and Berkshire Medical Center also provide opportunities in these and other rotations including pediatrics, neurology and psychiatry. “We will fit the additional sites to the specific rotations and look to more distant sites that have the facilities and technology, such as teleconferencing and electronic medical records that have value for students.”

Flotte said that UMMS plans to stay at the level of 125 students for a period of “settling in and reassessment. It will depend on how that transition goes. If, as those students complete their clinical years we get feedback that the sites are terrific, we will listen to that. A critical aspect of our planning process will be continuous evaluation from our faculty and students. We will obviously take our cues on the pace of expansion based on this information.”

Curriculum Changes Dovetail with Increase

As director of the Standardized Patient (SP) Program at UMMS, Wendy Gammon works with students during all four years of their medical school experience. The SP program provides highly trained actors who portray their patient roles for the students who conduct medical interviews, examine them and then receive the SP’s feedback. The UMMS program, with its more than 100 SPs, is one of the most highly regarded in the country, not only training medical school and nursing students here but for all three sister medical schools in Boston.

 

Gammon’s program sees every single student in their first year through small group medical interviewing practice sessions. In years two and three, students and SPs go one-on-one. During clerkship blocks, all students are allowed to take part in required multi-station clinical exams with SPs. It’s no surprise then that Gammon will be recruiting more of them as the class size increases.

The SP program is an essential component of the Medical School curriculum, which has been going through a multi-phased redesign process begun in 2005 with a completion date expected sometime in 2012. But instead of feeling trepidation about the effect of the class size increase on that redesign, educational leaders at UMMS are thrilled with the coincidence of these two transformative events. “This is an exciting time to reinvent, if you will, our medical school education,” said Dean Flotte.

“The stars are aligned on this in the sense that we have a vision for what we want our new curriculum to look like,” said Michele P. Pugnaire, MD, senior associate dean for Educational Affairs. “So we will take everything up a notch. It makes sense to do it all together. Growth in the class as we are redesigning the curriculum allows us to do it right the first time.”

For students interested in primary care, UMMS can invigorate the curriculum to encourage long-term relationships between students and faculty and students and patients, said Dr. Pugnaire. “Continuity is one of the greater rewards for students in primary care and we should shore this up,” she said. “The growth in size is right in keeping with where we are going anyway, which is more opportunity to learn interprofessionally, across all three schools at UMMS. All are pointing in the same direction with enhanced technology, experiential learning, faculty development, diversity and health care quality. The methods by which we teach and the resources we need are converging,” said Pugnaire.

That is particularly true when it comes to technology and the role it increasingly plays in today’s medical education. “The timing of the class size increase couldn’t be better because of our current initiatives to introduce additional state-of-the-art learning technologies,” said Chief Information Officer Robert P. Peterson. “The fact that the school has a plan allows us to make the correct investments in technologies that will improve the learning experience over time.”

The school has explored establishing an advanced learning center and enhancing its virtual microscopy classrooms, where students break into groups to study a variety of organs through digitized slides, and if a question comes up, the instructor can project the answer to the whole class in the form of a three-dimensional model.

“The trend now is for flexible space, with chairs and tables that fold up so you can arrange a room as a traditional lecture class or for small groups,” said Associate Chief Information Officer Ralph Zottola, PhD. “We’re in these processes because of the way student learning is being done; we’re moving from someone being at the head of the class to people breaking up into small teams.” All along the way, technology questions regarding hard wiring vs. wireless, sound systems, plasma screens, video conferencing and microphones come to the fore.

“The faculty is ready, in the sense that with the curriculum redesign, they are looking for technology in the classroom to support their educational objectives,” said Zottola. “It’s not just changing the class size; it’s changing how we teach.”