New Medical Schools Are the Growth Sector in Higher Education
a copy of the article was published in University Business magazine December 2015
Much of what one reads and hears today regarding higher education tends to dwell on constraints and reductions. But at least one sector of academe is actually experiencing substantial growth and expansion. New medical schools are in various states of planning, development or accreditation and existing schools are expanding class sizes, both portending perhaps the most growth of medical schools at any other time since the Second World War.
Signs of Growth
An April 2015 article in the Washington Post reported on same-day events, both involving the presence of president of George Mason University and the CEO of neighboring Inova Health System:
Both leaders envision growing the [northern Virginia’s] capacity to find advances in the prevention and treatment of cancer and other diseases with genetic origins. Both expect that the research they steward will lead to the creation of new businesses. And both plan to open a medical school
In May 2015 a senior official of Washington State University observed:
It’s not often a person has a chance to be part of starting a new medical school. We at Washington State University have been picturing what we want to create with a new WSU College of Medicine.
In fact, the chances of being involved in launching a new medical school have improved rather dramatically in recent years. The Association of American Medical Colleges reported in 2012:
Today’s level of growth of new medical schools has not been seen since the late 1960s and early 1970s. There were no new medical schools accredited in the United States from 1966 until Florida State was fully accredited in 2005. During that time, in fact, one medical school closed and two of the Philadelphia schools merged, reducing the number from 126 to 124. As of October 2012, the number . . . increased to 141.
In addition, the Liaison Committee on Medical Education lists 10 new medical schools with either Candidate or Applicant status (see http://www.lcme.org/directory.htm#pre-accredited-programs). To these can be added 14 osteopathic medical schools seeking accreditation from the Commission on Osteopathic College Accreditation.
What’s more, none of this reflects the planned or potential medical schools cited above in Virginia or Washington or elsewhere in some stage of public discussion or institutional planning. At a time when much talk within and about higher education is given over to shortages, the need to reduce or eliminate academic programs, and the lack of resources, medical schools are a growth industry.
Shortages of physicians are the primary reason cited for the creation of what are in fact very expensive undertakings. Indeed, projected shortages and at least one forecast of an oversupply have been the driving forces prompting both federal and state governments since the end of World War Two to intervene in medical education. Shortages of physicians alone are forecast to be more than 50,000 by 2020.
Add to this the incentives and disincentives built into the Affordable Care Act. Estimates of as many as 30 million people gaining access to health care could translate into still more demand for physicians and other health care professionals. This is especially the case in rural areas where access is already limited and particularly for primary care physicians who play a central role in ACA and who are already not available in sufficient numbers to meet current demand, not to mention increased demand generated by ACA.
But the rationale for creating new medical schools has changed of late and become more complex. Increasing the number of physicians remains an important rationale but it is often accompanied by an argument for the need for greater capacity for biomedical research, discovery and invention and accelerated translation of new insight into practical treatment methods and means. Much as breakthroughs in physics in the early 20th Century spawned a virtual explosion of insight and innovation, advances in the life sciences and, in particular, genomics are seen as sources with which to translate insight into new drugs and devices and novel protocols of treatment.
Testimony in support of this development can be heard in the speeches and reports of university presidents who cite the numerous startup companies both located near and often originating from their institutions. Biomedicine and bioengineering are, it seems, the 21st-century counterparts to 20th-century advances in physics.
That medical colleges are being established is all the more remarkable given the costs associated with their operation. At Ohio State University’s medical school, Year 1 cost for an Ohio resident is in excess of $51,000 and more than $70,000 for a non-resident. Medical students then confront debt payments as high as $3,300 per month over a quarter century.
Typically, facilities required to launch a medical school include a medical education building and housing for students. In 2008 when Hofstra University joined with a health system, the newly-appointed dean estimated the costs then for those two facilities would range from $50 to $100 million. More recently, the Texas Higher Education Coordinating Board staff projected the cost of a medical facility at $407 per square foot. Frequently, a significant philanthropic donation becomes quite literally the cornerstone of a new medical school. The remaining costs are financed through bonds, long-term institutional debt.
What’s more the lack of funding for medicine - and in particular medical research – “are creating a hostile work environment for scientists,” which, in turn, “is jeopardizing the future of research efforts and ultimately clinical medicine.”
Texas as Textbook Case of Medical School Growth
The Lone Star state is home to 27 million people and nine medical schools. By comparison, California’s population is almost 39 million and the state has 12 medical schools. Both states grew rapidly after World War Two, so population alone can account for the number of medical schools located in each.
But in the case of Texas, population pressure was accompanied by a push on the part of state leaders to improve the post secondary education system and to make Texas a center of biomedical research. Both goals were addressed by state legislation passed in 2009 identifying seven public universities as “emerging research universities” with the potential to join Rice, UT-Austin and Texas A&M as Tier One research institutions eligible for additional state funding.
Since passage of the Tier One legislation, the following medicine-related expansions have taken place or were explored in Texas:
- 2009 - Texas Tech opened a campus in El Paso named the Foster School of Medicine and established a graduate school of biomedical sciences
- 2009 – initial discussions of merger of University of Texas, San Antonio, and the University of Texas Health Sciences Center, San Antonio
- 2013 – University of North Texas Health Sciences Center added a College of Pharmacy
- 2014 – University of Houston president announced a study to ascertain whether to pursue adding a medical school
This last development is of special note given the sheer size and collaborations that have produced the Texas Medical Center in Houston: “21 . . . hospitals, 13 support organizations, eight academic and research institutions, six nursing programs, three public health organizations, three medical schools, two universities, two pharmacy schools, and a dental school” – “the largest medical complex in the world.”
Texas may be an unusual case, but the pattern of growth in medical schools across the nation sustains the notion that this is a sector of expansion in higher education, notwithstanding the high costs and uncertainty of government funding or reimbursement for treatment. But who will lead the new schools and what will they need to bring with them in launching new schools or expanding existing ones?
Given the constellation of challenges that confront new medical schools, leaders of these new organizations will require all of the attributes of the predecessors and the following:
- Interprofessional education has been talked about and promoted for years for medical schools and some have moved in the direction of active collaboration among the various health care professionals who will be involved in the delivery of care. The current environment and the impact of ACA puts extraordinary emphasis on physicians, nurses, pharmacists, physical therapists, social workers and others working together in a more systematic fashion, so deans of medicine are going to have to lead so that protocols and just plain old habits of doctors become more collaborative and less hierarchical. This may entail moving away from the traditional departmental organization of medical schools and toward more multi- and inter-disciplinary structures that facilitate collaboration within school and then with the other health professions. This type of change is not for the faint of heart as it can be seen by some physicians as undermining the value specialization brings to medical care and confusing decision making unnecessarily. More plainly put, a matrix or other type of organization may be viewed as reducing the status of doctors at a time when many physicians feel and express frustration at having to serve many masters, e.g., insurance companies.
- Save for a select few medical schools with ample resources at their disposal, most schools will need to strategically select or exploit areas of treatment and research excellence and forego efforts to make every field outstanding. Many schools have already adopted a strategy of “niche excellence.” Their newer schools will have to be more strategic in choosing a limited number of areas in which to excel, more conscious of what other schools are already excelling in, and very mindful of how treatment and research ought to reinforce one another. While determining which fields a school will strive to excel in need not be wholly a zero-sum choice, for those within the school whose areas of expertise are not selected almost invariably see themselves as “losing out.” A special kind of dean will be required to acknowledge the obvious truth of the situation – fields A, D and L are the ones to which attention and resources will be devoted – and yet retain the services and enthusiasm of those on staff whose fields of interest are B, E and M.
- A Corollary of the preceding push to focus on selected fields and excel therein may also put premiums on a dean who can scan the competitive landscape of other medical schools and elect to collaborate in order to compete. If neurology is the chosen field of excellence for Medical School 1, the dean of that school might elect to partner with Medical School 2 and that entity’s strength in oncology. In this way, resources are expended more systematically and the two schools in effect collaborate in order to continue to compete but do so without dissipating scare resources. Such a strategy will likely require a special sort of leader. Deans of medicine (indeed, deans of all kinds) tend to be competitive types and not naturally disposed to cooperate, so securing the services of a dean able to strive for excellence while working closely and positively with another school may be a challenge. One need not be a cockeyed optimist to sense that we are on the cusp of a revolution in biomedical research healthcare that could transform the lives of millions. And one need not be a cynic and despair at the scope of change that that transformation may entail or the likelihood that few leaders will be found who can harness the change. The history of change ought to caution anyone who thinks it comes easily. And that same history teaches us that change does eventually come and leadership can be an important catalyst.
Richard Skinner december 2015