Proceedings of the 21st National Conference: Consequences of Michigan's Strategic Initiatives for Medical Student Education

We gratefully acknowledge the sponsorship of the Sparrow Hospital/Michigan State University Family Medicine Residency Program of Lansing, Michigan for the transcription and editing of this section of the Proceedings of the Twenty-first National Conference.

The posting of the proceedings of this plenary session is part of a series of previous presentations on Community-based Medical Education that will be highlighted on this website. Such presentations are preparatory to discussions on this subject scheduled for the Twenty-third National Conference on Primary Health Care Access at the Park Hyatt Aviara Resort in Carlsbad, Caloifornia April 16-18, 2012. 

From the Third Plenary Session of the 21st National Conference on Primary Health Care Access:

Robert Ross, MD, Oregon Health Sciences University/Cascades East Family Medicine, Klamath Falls (Moderator):  I’d like to welcome Dr. Daniel Webster, from Michigan State University, Traverse City, to give us our first topic of the morning, “Strategic Interventions in the State of Michigan”.

Daniel Webster, MD; Michigan State University, Traverse City

Daniel Webster, MD, Michigan State University, Traverse City: I’d been encouraged for many years by Doctors Bill Wadland, MD, George Smith, MD,  and Beth Burns, MD, who have all attended the National Conferences before, as has Dr Linda Garcia-Shelton. All have spoken very highly of them, so last year I attended a National Conference for the first time.

Introductory Comments

Officially, I’m a family physician who graduated from Northwestern University in 1979, attended Michigan State University (MSU)  College for Human Medicine, and then trained in a family medicine residency in Grand Rapids, Michigan.

I entered practice in a town called Traverse City and ran a family practice there for 14 years. Then in 1996 I left private practice to start a dually accredited (MD and DO) family practice residency.

I was director of that residency for 14 years. Dr Perry Pugno (Director of Education at the American Academy of Family Physicians and a Senior Fellow of the National Conferences) has been my mentor since 1995.

About two years ago, we started the seventh campus for MSU’s College of Human Medicine. I am the Assistant Dean in Traverse City for the MSU campus, my third career in the same town  – as family physician, residency director and now assistant dean.

I will speak about the consequences of Michigan’s strategic initiatives for medical student education. First, I will provide some general information about the growth in medical student education in the State of Michigan and then talk specifically about growth in the  College of Human Medicine (CHM). I’ll discuss some success stories and also some stories yet to be evaluated as success stories.

Earlier in the conference we talked about the Baby Boomers, This is a generation that we in Michigan are looking at too.   I’ll present this in little chronological steps going back to 2005, look at the present, 2010, and forward to 2015, as to what worked and what didn’t go so well.

Michigan’s Geography and its Medical Schools

When you look at the geography of the state of Michigan, you can see there is a lower peninsula and an upper peninsula.  News media reports sometimes forget the upper peninsula is actually part of Michigan. The upper peninsula is not a separate state.

I will give you some driving distances – Traverse City to Lansing,  the main campus of MSU CHM, is a three hour drive. To drive to Lansing for several hours of meetings, then return home to Traverse City is a good day’s journey. We have a campus in Marquette, eight hours away, as well. The other campuses are in Grand Rapids, Kalamazoo in Southwest Michigan, Flint and Saginaw.

The stakeholders in this effort are Wayne State University, University of Michigan and MSU.

MSU has two medical schools on the same campus – CHM (allopathic), and the College of Osteopathic Medicine. Both are housed in East Lansing. The others are Wayne State in Detroit and the University of Michigan at Ann Arbor. These produced 581 students per year in total, as of 2005.

I alluded to the MSU CHM campuses. The allopathic four year campus is in East Lansing. The two year campuses (where specific students do their third and fourth years of medical school) are in Lansing, Kalamazoo, Flint, Saginaw, Marquette, Traverse City and Grand Rapids. MSU’s College of Osteopathic Medicine has their first two years in East Lansing as well. But then the students spread out and do the preceptorship model and the base hospital model, with the students going to approximately 17 hospitals in the state of Michigan. The University of Michigan’s activities are located mostly around Ann Arbor and Wayne State around Detroit.

In 2004-2005, there was a Michigan workforce study that showed that the ratio of primary care physicians to specialty care at that time was 34 to 66. 39% of physicians practicing in Michigan had attended a Michigan medical school, and 61% had completed a Michigan residency. Michigan ranked fourth in the United States of students in a public medical school. The study projected a State shortfall of 4500 physicians over all and a State shortfall of 600 Family Physicians.

These figures seemed low to me at that time. However, this drove some of the State’s medical schools to increase their enrollment sizes, which they were already in the process of doing. The study was revisited at in 2008. The percent of primary care to specialty care hadn’t changed. The study found that in 2008 almost 80% of the physicians were planning to maintain their current practice patterns or to increase their hours of practice.The study also that the female/male physician ratio was  50/50, and that, as in all other states, the population was aging.

Meanwhile, Michigan has its  economic problems, with an unemployment rate at almost 15% in April 2010. Because of severe shortfalls in the general fund for supporting medical education, these original stakeholders have been told to absorb state funding cuts of 23% over three years. Yet, there greater numbers of uninsured, who are increasingly seeking medical care in Emergency Rooms.

Currently, there are 1,051 graduate medical education (GME) positions in Michigan, with roughly one-third being in primary care medicine. Of these 317 primary care GME positions only 99 are in family medicine, comprising only 10% of Michigan’s GME positions.

The next slide clearly shows the impact of medical school expansion. In 2010, the total has increased from 2005’s 581 to 925 medical students per year. Through this increase of 344 medical school positions, Michigan’s physician workforce is being redesigned – although perhaps not for all the right reasons.

Only the University of Michigan stays at the same level, but Wayne State increases rapidly from 200 to 300 graduates. Michigan State’s CHM jumps from 106 to 200, opening one new campus and expanding the combined Midland-Saginaw campus. The College of Osteopathic Medicine (COM) has increased as well from 100 to 250. COM’s growth is towards Detroit, so they’ve entered the competitive market for clinical sites in Ann Arbor (home of the University of Michigan) and Detroit (home of Wayne State).

The next slide shows where the campuses are. Wayne State (labelled WSU) and Michigan (UM) are in the Southeast and MSU’s four year osteopathic medical school (COM) and College of Human Medicine (here, labelled CH) are on  the main campus in East Lansing.

But simultaneously, MSU’s CHM, is launching a four year campus.  Thus, MSU will have two four year campuses, one in Grand Rapids and one in Lansing. They’ll split the students equally between those two campuses in the first two years. The MSU CHM Dean, Marsha Rappley, MD, divides her time equally betwen the two campuses. (It’s an hour’s drive between them.)

Expansion of Community-Based Medical Education raining into New Areas

The students will then be distributed for the next two years to the other community campuses, and will either be assigned to Marquette, Traverse City, Kalamazoo, Flint, the combined campus of Saginaw-Midland, or they’ll stay in either East Lansing or Grand Rapids.  COM, I’ve already mentioned, is expanding to Southeast Michigan, towards Detroit.

Also in 2010 some new stakeholders have entered the scene. These include Western Michigan University, Central Michigan University, and Oakland University. Oakland University’s medical school in Oakland County (in the greater Detroit suburbs) is on board to start partnering with William Beaumont Hospital, admitting 50 medical students starting in Fall 2011.

I visited Central Michigan University in Mount Pleasant just a couple weeks ago. They will  have 100 students starting in 2012.  Western Michigan University (Kalamazoo) is planning for 50 students, although they don’t have a start date as of  yet.

Impending Shortage of Medical Student Preceptors

One of the concerns is that when you start adding more students and more medical schools, as you all know, you only have so many preceptors to go around. There is now competition in  Michigan for the development of training centers for all of these medical students. The map gets a little busier. We still have CHM and COM primarily in East Lansing, but CHM’s four year campus in Grand Rapids is added.

Two of these campuses – Grand Rapids and East Lansing – are providing identical services and an identical curriculum. Oakland University (OU) is in Rochester, and Central Michigan University is located in Mount Pleasant. Meanwhile, Western Michigan University is in Kalamazoo, one of our community campus sites. That creates some friction as well.

The problem with finding preceptorship sites is not so much the case in the Traverse City area, because we’re a brand new area for CHM. Although we have been a base hospital for the MSU College of Osteopathic Medicine, with regard to CHM, we have a lot of volunteer faculty that are eager to teach the students. But there is more competition for community preceptors in Kalamazoo and Saginaw and, obviously, in the Detroit area.

Faculty Development for Community Preceptors

All of the campuses, including ours, are engaged in faculty development programs for our preceptors. The last thing we want to do is ask somebody to teach and not help them with the skills they need to teach. The preceptors want that information.

MSU and Medical Education

Next, I will discuss MSU’s progress over the the last couple of years.

As the slide above indicates, MSU is a land grant institution in an auto producing state – an industry that has created some of our major current economic problems.

CHM is a college of Michigan State University, which is a land grant institution. CHM was founded in the 1960s and 1970s to encourage the training of primary care physicians. At one time we had 25% of our graduates going into family medicine. That has changed. Of the 46% entering primary care in 2010, only 9% went into family medicine.

41% remain in the state 43% entered primary care in 2008 and you can see the results down to 2010.

Sometimes it’s confusing as to which medical college you’re looking for, because they’re all in the same building.  (At MSU they say we have three medical colleges because they include the veterinary school.) There is no hospital on the MSU campus itself, although we have hospitals in each of our community sites.

The photograph is of East Fee Hall. When Dr Allan Wilke (a Senior Fellow of the Coastal Research Group) and I were undergrads, that was a dormitory. All of the COM’s offices used to be old dorm rooms.

That’s where we are now with the CHM – the school I’m associated with at this time. I was its residency director as well. We had a family practice residency network that had nine residencies located across the state.

These are the players in my culture right now. There’s a fair amount of friction because Central Michigan University is talking about expanding north, so they would be expanding into where my preceptors come from. We have Kalamazoo Western potentially starting a medical school, and if they do, MSU will pull out of Kalamazoo. Where those students will go, I’m not exactly sure, although I think some of them will end up in Traverse City.

Meanwhile, Saginaw and Midland have plans to combine into one campus as well.

All of the campuses have teaching hospitals, rather than having just one major academic teaching hospital. In Traverse City our teaching hospital, Munson Medical Center, is the hospital where I have had privileges for over 30 years.

This slide gives you a few statistics. Munson Medical Center is a major employer in the area. It currently is going through affiliation talks with Grand Rapids Spectrum Hospital. Whether that’s good or bad, I haven’t determined yet.

When we pose the question to our board as to why should we have a clinical campus in Traverse City, they cite that previous Michigan work-force study that I referred to. The board thought it was good for recruitment, retention and academic stimulation and provided an opportunity to meet rural health care needs. They thought it would help the institutional reputation, as well.

For the first two years – the year starting July 2009 and the coming year starting in July 2010 –  students had already been assigned to clinical campuses. For that reason, we had to recruit pilot students. We have six pilot students for the current year. Four of them are from California, two of them are from Michigan – actually one of them is from Traverse City, and she plans to go into primary care and stay in Traverse City. The four from California plan on going back to California.

Eight months later they’re still happy, and having a good time.

The slide below describes the Traverse City curriculum, which is similar to most medical school curricula, with basic science in the first year and problem-based learning in the second.

 Then in the third year, we have six clerkships, each that are eight weeks long, using the same curriculum across all clinical campuses.  Our campuses are based on a model called Regional Medical Campuses or Disseminated Medical Campuses. (The Canadians use the term “Fully Distributed Medical Campuses”).

Each campus has a clerkship director for each of these specialties and coordinating them is a lead clerkship director for each of these specialties.  This creates a network that delivers the same curriculum across all community campuses. We are fortunate in our family medicine programs to have the students for eight weeks. I take them myself, and am also the family medicine clerkship director in Traverse City.

In Traverse City, I place them in both the rural sites and in sites in Traverse City. They work in the hospital for a week. They are in the Traverse City Health Clinic, which is a free clinic, serving migrants and Native Americans. I try to expose them to all aspects of primary care, similar to Marquette, which does the same thing

The Marquette training site is fortunate to be located in the Upper Peninsula. It geographic situation and curriculum are similar to the rural sites used in the Minnesota program described yesterday by Doctor Macaran Baird. Both the Upper Peninsula and Minnesota rural students have 12 weeks of family medicine.

The Marquette site has a higher percentage going into family medicine, as well as a higher percentage of family docs staying in the Upper Peninsula. They also either go through the residency in Marquette or they go to another residency and return to the area.

(In this morning’s breakout session, Doctor Baird confirmed that the Minnesota data parallels our findings about those training in Michigan’s Upper Peninsula.)

Then in the fourth year we have four week required clerkships in advanced medicine or senior surgery, and then they choose their electives.

The CHM Longitudinal Curriculum

I’ve been in residency education for 14 years and I’ve only been in medical student education for about 16 months. So it’s taken me awhile to learn it. But what’s really nice about the CHM curriculum is the longitudinal component.

The curriculum includes gateway assessments, which are simulation labs, back in Lansing or Grand Rapids. Gateway assessments related to physical exams occur in the second and third years. There is also an Evidence-based Medicine gateway exam as well.

There’s a huge curriculum on professionalism included in our evaluation forms as well. Patient safety is a curriculum component, as is the ethics curriculum, and these subjects are integrated in the curriculum from the first year through the fourth year.

A new requirement is community service (which most of the students have been doing anyway, but now it’s an educational requirement, for a minimum of 40 hours over the four year curriculum. There is a research project in the third year as part of their Evidence-based Medicine curriculum.

To give you an example, our students are doing a medication error reduction research project, by means of a survey of pharmacies to see what rate of medication errors there are in prescription writing, whether from an electronic FAX, email or hand-written prescriptions.

For community service, we paired up with our local high school. The slide below shows one of our third year students, co-teaching anatomy and physiology. (I heard from several of you at this conference that this is being done at other medical schools also.)

Student Demographics, Tuition and Debt

This slide presents some of our demographics, with 66% of the students across all campuses coming from Michigan and 34% from out of state. The general distribution is as noted below, although the tuition is actually higher. Tuition is now up to about $30,000 a year for instate students, and closer to $60,000 per year for out of state students. I’ve been told it’s the highest tuition in the nation for a public institution.

One reason for the high tuition is that part of the tuition comes back to operate the medical school. When you have that many campuses, with that many levels of administration and that many requirements across the state, it’s not an inexpensive way to deliver medical education.

I’ve been told by the six students I have in Traverse City, that their average debt approaches $210,000 at this point.

Summary and Issues for Further Consideration

When considering the future needs of medical education in Michigan, we need more slots for primary care, specifically family medicine. We need something to help with loan repayment for students, just as do those of you from other states. We need some help with our insurance reimbursement for primary care. Hopefully, that is coming through the healthcare reform bill, although not until 2014.

You’ll find, as I did, students like their electronics. They want a practice that has electronic medical records. The generation of students we are teaching is looking for the quality of life (not that those of us who have been in practice for thirtysome years aren’t looking for it also). The students will want to limit their call. So those are all concerns we’re going to have to deal with.

Much of this increase in student medical education has occurred in a nonsystematic manner. Each school took it upon themselves to increase their medical school class size. The increase in CHM medical schools’ class size was driven by the desire of the Grand Rapids’ community to have their own four year medical school in partnership with MSU.

That’s why we have two parallel tracks, East Lansing and Grand Rapids, that are only 58 miles apart.The fact is that CMU, Western and Oakland are each developing medical schools with no workforce plan connected to the other three institutions speaks to that.

I’ve noticed in working with medical students is that when they come into medical school, they want to take care of the whole patient. They want to enjoy the practice of medicine, and they want to provide some value or trust to the culture of medicine. Myself, CHM, and all of us in this room just need to figure out how we can do that best. Thank you!