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USA medical school works to satisfy accreditors


03/08/04

By JEFF AMY
Staff Reporter


Leaders of the University of South Alabama's medical school are working on changes to how classes are taught and what professors are expected to do, in part because of criticism last year by the group that accredits medical schools.


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But some of the areas where USA isn't meeting national standards may be hard to remedy by the time reviewers return this September, particularly a claim that the school doesn't employ enough clinical faculty. The number of clinical faculty has fallen from 204 in 1995 to 132 today.

Accreditors didn't say in correspondence exactly how many faculty they believed would be adequate, and won't comment on issues related to specific schools.

A lack of faculty has also hampered separate reaccreditation for two USA programs that train medical residents to treat lung disease and heart disease, although officials say enough doctors have now been hired to properly run training in those specialties.

Dr. Robert Kreisberg, dean of the College of Medicine at the 13,000-student university, said the school's accreditation is not in serious or immediate danger, and said the school will make the reforms nec essary to satisfy its accrediting body, the Liaison Committee on Medical Education.

"We're working on every single item they've identified," Kreisberg said.

Those shortcomings named by the LCME included:

An over-reliance on traditional lectures to teach students during their first two years, instead of the small-group and self-directed activities for which accreditors are calling.

Inadequate clinical teaching of psychiatry.

Not enough preparation for residents who help teach and evaluate upper-level medical students during clerkships -- short rotations through medical specialties.

Inconsistent and inadequate evaluations for clerkships.

Too few clinical faculty members and not enough scholarly research by clinical faculty members.

Unclear policies for hiring, firing, promoting and tenuring of faculty, as well as a lack of standard evaluations of the performance of untenured faculty.

Under federal rules, USA had two years starting in February 2003 to fix any deficiencies.

The liaison committee accredits 126 medical schools in the United States and 16 in Canada. The committee is a joint venture between the American Medical Association and the Association of American Medical Colleges.

Accreditation for medical schools mirrors in most ways the process for universities. It's meant to make sure that a school meets basic standards, and has the resources to adequately do a job. Most state medical boards won't license graduates of unaccredited schools. Also, without the seal of the LCME, medical students wouldn't be eligible for federal student loans.

USA's medical school opened in 1973. The LCME has made a comprehensive review of the school's accreditation every seven years, a cycle that is now stretching to eight years. It starts with the school doing a self assessment, a review of all aspects of the school's operation, including a survey of students. An LCME team then visits, and their findings are passed on to the full committee.

In USA's case, a six-person survey team visited in September 2002, and the committee took action in February 2003. The LCME continued accreditation for another full term, but voted that another survey team needed to return in September 2004 to look at specific areas where it felt USA wasn't meeting national guidelines.

The LCME report praised the quality of teaching at USA, noting that students do well on national exams, and that many win spots in respected residency programs. It also commended Kreisberg, saying he "has provided stability of leadership and has promoted institutional growth, enhanced academic standards and fiscal responsibility.

The committee also said that USA has gotten better at managing its course of study, thanks to the leadership of Dr. Betsy *******, the vice dean for student affairs and medical education. Finally, the LCME saluted USA Children's and Women's Hospital as an excellent teaching asset.

Dr. Frank *****, one of the two leaders of the LCME, said the committee commonly asks for follow-up on its concerns in three ways -- written progress reports, a follow-up visit by LCME staff, or a follow-up visit by another team of volunteer accreditors.

USA will be visited by nonstaff accreditors, which ***** says is typical when the committee feels it needs to interview faculty and students, or when issues to be considered are more complex. Many LCME standards are based on human judgments of adequacy, not numerical yardsticks.

"That's part of the value of the process," ***** said. "It's not a check-list."

An additional visit is relatively common. The LCME web site indicates that the committee will revisit six of 29 medical schools that were up for full accreditation in 2002-2003. At least three of 25 medical schools that had full surveys in 2001-2002 are receiving additional visits this school year.

The LCME has the option to put schools on probation, a step towards revoking accreditation, but seldom does so. The University of Saskatchewan is the only school currently on probation.

Philadelphia's Temple University was on probation from February 2003 until last month. Besides Temple, the only other American medical schools to receive probation in the last 15 years were two Puerto Rican institutions.

The University of Hawaii's medical school was threatened with probation in 2002, but was only required to undergo an additional site visit.

Kreisberg, dean since 1999, said USA was surprised when the LCME findings came back, because some of the overall committee's concerns were not mentioned by the visiting team. The full LCME reserves the right to come to different conclusions than the visiting team, though.

What appeared to prompt the harsher findings by the full committee was that many concerns were in the same areas as had been noted in USA's 1995 accreditation. After that review, the LCME required a progress report in 1997, a visit by LCME employees in 1998, and another progress report in 2000.


Small school's problems:




At USA, medical school faculty are divided between professors in basic medical sciences and clinical sciences. Basic medical science faculty typically do basic research, publish their findings and teach foundational classes to first and second-year medical students. However, they may not be medical doctors, and typically don't see patients or teach upper-division students at USA's hospitals and clinics.

Clinical faculty, on the other hand, typically do research that is more focused on immediate medical problems, see patients, and teach residents and medical students in their last two years how to apply what they've learned in earlier classes.

USA's basic medical science faculty has grown slightly over the years, but the 35 percent decline in clinical faculty concerned accreditors.

USA's medical school, with fewer than 250 students, is among the nation's smallest. Kreisberg argues that USA may be under the gun in part because of its overall small size, even though the student body scores at or above national averages on medical licensing exams.

USA has consciously chosen to shed some doctors. Between 1999 and 2001, USA closed its cancer treatment, ophthalmology, dermatology and allergy divisions. The number of clinical faculty members, which reached a high of 204 in 1995, fell from 169 in 1998 to a low of 125 in 2002. Since then, seven clinical faculty have been added.

One of the discarded divisions -- cancer treatment -- is coming back in a big way with the school's new cancer research institute. So far, the doctors hired for the institute are mainly focused on research, but the university plans to hire doctors to provide treatment soon.

But small numbers of faculty mean that a few departures can put some specialty programs in peril. USA has 15 residency training programs in various medical specialties. After four years of medical school, a student moves on to residency training, typically three or four years in a broad specialty, such as internal medicine. After that, residents may move into training in a subspecialty, such as gastroenterology -- treating diseases of the digestive tract.

USA's residency programs are accredited by a separate group from the LCME, called the Accrediting Council for Graduate Medical Education. Only residents who complete programs approved by that council can sit for exams to become board certified in specialty areas. Programs approved by the council also are eligible for federal Medicare funds to train residents.

Four small USA specialty residency programs were placed on warning status in 2002. Two of those -- gastroenterology and cardiovascular disease -- were faulted for having fewer than the minimum number of faculty.

Dr. Jack DiPalma, who heads the gastroenterology program, said the school has worked out contracts to hire two more doctors who will meet standards as faculty, adding them to the current two to reach the minimum number of four.

DiPalma said that many subspecialty doctors don't want to work at universities, because they can make more money in private practice.

"This is a nationwide trend, that young people are not choosing academic careers," DiPalma said. "Certainly, lucrative specialties in the private community don't have the same appeal in the academic sector."

Dr. Clara Massey, who heads the cardiovascular disease program, could not be reached for comment. The program has to have at least six faculty members to teach its four residents, according to accreditation records, and only had five faculty members at last note.

Accreditation issues for the two-resident pulmonary disease program were mainly related to curriculum and research, according to records and Dr. Ron Allison, its director. Those for the infectious disease program were related to a student who left the two-resident program, making the site visitor question its continuity, according to Dr. Keith Ramsey, the program's director.

Visitors from the council were at USA last week, assessing whether the programs -- the other two were pulmonary disease and infectious disease -- have made required improvements. The council will act on their findings at a later date.


Too many lectures:




Another important criticism from LCME is that first-year and second-year medical students spend too much time listening to lectures, and not enough time teaching themselves or learning from real-world examples.

Accreditors want students to learn on their own, not just from professors, because doctors have to keep up with developments in their fields and try to learn lessons from problems they seen in patients.

"You have to develop those skills, that independent study, because when you graduate from medical school, that's how you keep learning," said the LCME's *****.

In practice, that means that accreditors encourage beginning students to meet in small groups and discuss cases that are typically presented on paper. USA has instituted such small-group meetings to discuss clinical applications of concepts presented in lectures, Kreisberg said.

However, USA also has appointed an assistant dean for curriculum, who is exploring organization of classes in different ways with more focus on practical application.

There is some resistance to too much change, though, in part because students perform well under the current system. Microbiology professor John Foster, for example, said he believes that it helps students extract relevant lessons from a large mass of scholarly literature more quickly and easily than they could on their own.

"They seem to need a clear, concise presentation, where somebody goes into the literature and boils it down into something meaningful," Foster said.

Some of the LCME's other concerns are less deeply rooted, and appear easier to fix. For example, Kreisberg said reviews are now issued to medical students during the middle of each clerkship, in an effort to clear up concerns that students weren't getting enough guidance on whether they were meeting expectations.

Kreisberg said he hopes USA is making progress on another nagging problem -- psychiatry instruction. Because many psychiatric patients are no longer seen in hospital settings, USA has traditionally had trouble providing enough patients to make a student's clerkship meaningful, or to guarantee that faculty members are earning enough money to pay for the department. The school decided to combine psychiatry and neurology into one clerkship.

The university has branched out to try to provide opportunities for students to see patients in non-USA locations. It has also extended the clerkship by two weeks, to address concerns that there wasn't enough time to get the necessary education.

Overall, faculty members seemed little concerned about the LCME report, and confident that the medical school would be able to satisfy the accrediting body.

"Every medical school comes up with some issues they have to fix," Kreisberg said. "No place is perfect, not even Harvard."

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