Dean's Newsletter

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Year-end report: Where do we stand and where are we going?

December 30, 2005

As the year draws to a close, I thought it would be a good time to take stock: Where do we stand as a medical school and where are we going? To assess where we now stand, at the end of 2005, in this newsletter (Part 1) I will provide some data and commentary on a variety of measures, along with national benchmark comparisons where possible. To give my assessment of where we are heading, in next week's newsletter (Part 2) I will discuss some of the key challenges facing URSMD--both financial and cultural--along with the opportunities that lie before us.

To set the stage, it is important to appreciate that we are a mid-sized medical school. From the 2005 AAMC report, which was based on 2003 data, we were at about the 55th percentile in total full-time faculty. Commensurate with our faculty size, we were at the 55th percentile in total revenues (research, clinical practice, endowment income, etc.) among private U.S. medical schools: the national median was $456 million, while our total revenues were $538 million. Importantly, however, our compounded annual growth rate in total revenues over the prior five years was 9.9%, which places us in the 75th percentile of growth rates among private U.S. medical schools. This robust growth in revenues is due to the productivity of our faculty in both clinical practice and research funding.

In the next two newsletters, I will focus on our education and research missions. Within these two missions, I will highlight key issues rather than attempt to be encyclopedic. Thus, many important aspects of education and research at SMD will not make it to this "highlights" reel. In upcoming weeks, I will devote separate newsletters to our clinical and community health missions.

1. Undergraduate Medical Education

A. Class size

Data: We have enrolled approximately 100 students in each entering class of the URSMD since the 1970's. Nationally, there has been a very slight rise in the number of students admitted to U.S. allopathic (M.D.) medical schools. Through 2004, this amounted to an increase of only 50-100 per year in the number of students nationally. In 2005, however, the number of students nationally increased by 357, from 16,648 to 17,005.

Comment: How many doctors should be educated in U.S. allopathic medical schools? Addressing this question in a thoughtful manner involves many complex issues, including the need to address a projected physician shortage (assuming no fundamental change in our system of health care, including the mix of physicians and mid-level providers) and the increasing supply of newly minted physicians from schools of osteopathy, from U.S. citizens attending off-shore medical schools (e.g., Granada), and from foreign medical graduates entering U.S. residency programs. The AAMC has recommended an increase in the number of allopathic medical school graduates by 15%. The question for us is: Should we contribute our "share" to a larger number of physicians educated in our high-quality (and high cost) environment, and can this be done without comprising the level of talent among our students and the quality of their experience? This will be an important question in our educational strategic plan as that process moves forward.

B. Curriculum

Data: The medical school curriculum has been grounded in the biopsychosocial tradition founded by Engels and Romano. The Double Helix Curriculum, introduced in the 1990s, is another well-recognized Rochester innovation that has become incorporated into the fabric of our curriculum. According to exit surveys at URSMD and other U.S. medical schools nationally, 58.2% of students at URSMD anticipated becoming full-time university faculty vs 32.8% nationally. Moreover, 20.3% expected to be "significantly involved" in research, vs 15.0% nationally.

Comment: We remain committed to the biopsychosocial model and the Double Helix Curriculum as core elements of medical education. Building on this foundation, in recent years we have emphasized academic rigor and have provided enhanced opportunities for students who wish to pursue a career in academic medicine. Thus, we have doubled the size of our MD/PhD program (from 4-8 entering students per year), directed by M. Kerry O'Banion, MD, PhD; a critical mass of these students is being established. In addition, we have initiated the Academic Research Track (ART), coordinated by Robert Gross, MD, PhD, which provides an enriched curriculum for students interested in pursuing research during medical school. ART includes a mentored year-out experience working on a specific area of basic, translational or clinical research. Most fundamentally, under the leadership of David Lambert, MD, Associate Dean for Undergraduate Medical Education, each element in the Double Helix Curriculum is under continuous review, incorporating feedback from students and faculty with an eye towards improving the overall student experience while increasing academic rigor.

C. National Ranking

Data: Our overall rank in U.S. News and World Report among 125 allopathic medical schools is 30, but our selectivity rank, which is based on mean MCAT, mean GPA and acceptance rate, improved from a rank of 30 in 2003 to 22 in 2005.

Comment: U.S. News and World Report rankings are largely based on a peer assessment and other measures. The all important peer assessment measure is highly correlated with NIH research rankings, which, in turn, are strongly associated with medical school size. After peer assessment, selectivity is statistically the most important contributor to this ranking system. If our improved selectivity persists in future years, we'll take that to mean that the reputation of the medical school has indeed been recognized by medical school applicants nationally. This enhanced talent pool can only have a positive impact on the medical school generally and, as a by-product, on improved peer assessment.

D. Financial Aid

Data: Although the number of medical students is at the 15th percentile nationally among private medical schools, out total financial aid to students is almost at the 60th percentile nationally ($3.8 million).

Comment: These data imply a high level of aid per student relative to other private medical schools. Despite this, mean student indebtedness is now $130,000 at the end of medical school (see September 29, 2005 Newsletter). A little over a year ago, I announced a fundraising campaign for $10 million toward student scholarships. We are already more than half the way there. In the future, there will be an even greater emphasis on the need to raise a substantial endowment for medical school scholarships towards the ultimate goal of a tuition-free Rochester.

2. Graduate Medical Education

A. Size and Cost

Data: We run 68 residency and fellowship programs, containing a total of approximately 500 residents and 100 fellows. In 1997, Graduate Medical Education payments to our health system were capped at 500. The 100 additional residents and fellows have been largely being paid from hospital revenues, with some contribution from training grants and departmental resources.

Comment: In recent years, the demand for residents and fellows by our clinical departments has expanded dramatically. This has been due to a dramatic expansion in the clinical enterprise, combined with reduced resident and fellow work hours and an increased proportion of those hours devoted to educational activities rather than direct patient service. A major share of the increased need for inpatient services has been addressed by developing a large hospitalist program and by increasing the number of nurse practitioners, clinical nurse specialists, and physicians assistants. That said, as noted above residents and fellows have also increased to a level that is 100 FTEs above the cap. A high-level committee consisting of URMC leadership and the Associate Dean for Graduate Medical Education performs a formal review of all requests for additional resident or fellow positions on a regularly-scheduled basis. Our goal is to foster the highest educational quality in our GME programs, balanced against service needs and budgetary realities.

B. Resident match

Data: Of all resident positions available at URMC, 95% were filled by U.S. graduates, as compared to 62% of residency positions nationally filled by U.S. graduates.

Comment: Although using percent U.S. grads as a quality measure is imperfect, since foreign medical graduates often bring valuable prior clinical training and/or research experience, these data nonetheless point to the highly competitive nature of most of our residency programs. Residency training is at the core of any clinical department. The ability of a department to attract the best medical students nationally to their residency program reflects upon its overall quality and recognition.

C. Training Rochester's doctors

Data: In 2005, 45% of 119 graduating residents remained in Rochester, as did 48% of 50 graduating fellows.

Comment: A major benefit to the Rochester community of our residencies and fellowships is the training of physicians who remain in the region to practice. We train the lion's share of specialists and subspecialists who remain to practice in the region, not only in the URMC system, but in other health systems as well.

D. Commendation

Data: In 2005, the University of Rochester Medical Center was the first institution in the nation to receive six years of accreditation from the ACGME.

Comment: Under the leadership of Diane Hartmann, MD, Associate Dean for Graduate Medical Education, URSMD was "the first medical school to be judged by the Institutional Review Committee to earn this distinction", according to Cynthia Taradejna, Executive Director of the Accreditation Council for Graduate Medical Education. This is an extraordinary achievement that reflects the high level of performance of residency and fellowship program directors who work with Dr. Hartmann to meet ACGME benchmarks and standards in a uniform fashion.

3. Graduate Education

A. Size

Data: Although we are only at the 15th percentile in the size of our entering medical school class, we are in the 85th percentile of medical schools in the size of our Ph.D. program. In 2005, 80 students were admitted to our Ph.D. programs; in total, 412 Ph.D. students are enrolled. In addition, there are about 100 master's level students, both M.S. and M.P.H.

Comment: The growth in our graduate education programs has paralleled the growth in our overall research enterprise. The size of this enterprise has roughly doubled in the past decade, whether measured by faculty numbers or by the dollar amount of external funding. As the number of basic scientists increases, so does the opportunity for Ph.D. education in their laboratories. Moreover, as clinical research has expanded, junior faculty members in clinical departments increasingly pursue an MPH, recognizing clinical research as an important part of their career. This option has been accelerated by the K30 curriculum award to Dr. Tom Pearson from the NIH.

B. Institutional Cost

Data: The net cost of graduate education to URSMD can be calculated as the sum of stipends (net of grants for stipends) plus faculty effort specific to graduate student teaching (net of grants for graduate school tuition). This sum, which was $2.8 million in 2005, has more than doubled over the past five years.

Comment: A "hidden" but critically important cost of expanding the research enterprise, about which I suspect most members of the URSMD community are not aware, is the cost of graduate education. Given that the overall size of URSMD's research program has doubled, as noted above, it is not surprising that the cost of graduate education has also doubled. In our current strategic planning for education, when we consider the cost of expanding specific research programs, we must consider not only the cost of faculty recruitment, start-up packages, equipment, facility construction, renovation, etc., but also the cost of expanding the cost of graduate education.

C. New Degree Programs

Data: The environment is changing for employment of PhD scientists. While there will always be a need for biomedical investigators who do investigator-initiated, independent research in fundamental science, which is the focus of our PhD educational programs, NIH is emphasizing the need for translational scientists and industry is demanding scientists with a broad biomedical training and a background in the principles and practice of the business world.

Comment: To address these needs, we are considering two new PhD degree programs: one is a combination PhD-MBA program with the Simon School, and the other is a PhD program in translational science.

4. Research

A. Historical Perspective

Data: A strategic investment in research that began in the mid-1990s resulted in a substantial rise in NIH funding. This curtailed the rapid decline in NIH ranking that had occurred in the late 1980s and early 90s, which was due to a slowing of recruitment and poor retention of investigators. While the curve in NIH ranking has now plateaued, it has not yet begun to improve. In these newsletters, I have thus far avoided embedding figures in order to minimize the size of the file being transmitted, but the graph below is so dramatic that I include it here. It tells the story in a manner that is more compelling than the words above.

Comment: There is no question about the importance and timeliness of the mid-1990's decision to invigorate basic science research at URSMD. As a result of this Strategic Plan, approved by the Trustees in 1996 and implemented since that time, we have doubled the number of investigators and created excitement about the future of scientific investigation at URSMD. This scientific work, whether in existing departments or in newly created research centers, is supported by renovated or newly constructed facilities, enhanced scientific cores, and most importantly by a collaborative spirit that has fostered many interdisciplinary programs that have now been funded as Centers or Program Projects by NIH or other federal agencies. It is remarkable to consider the amounts of people and financial resources that were needed to break the fall in NIH ranking. Had this investment not been made, our NIH ranking would have no doubt continued to plummet. Having made the investment, we now have a substantial increase in scientific output and federal funding. As will be discussed in Part 2 of this newsletter next week, I believe that we have now developed a critical mass for turning the corner and moving up the NIH ranking list.

B. Diversification and Balance in Research Portfolio

Data: In contrast to the distribution of NIH funding between basic and clinical science, which is about 2/3:1/3, sponsored research funding at URSMD—both federal and nonfederal—is about 50:50 between clinical and basic research. Moreover, the content of this research is broadly diversified across our many Departments and Centers.

Comment: The balance that we have as an institution between basic and clinical research, along with a substantial amount of translational research that is embedded in both of these categories, puts us in an excellent position to take advantage of the direction in which NIH is proceeding along its "Roadmap". Diversification of our research portfolio across different content areas protects us against the downside risk that might occur if all of our "eggs were in one basket".

C. Contraction of NIH Budget and Research Tracking

Data: The doubling of the NIH budget that has occurred over the past decade has now come to a screeching halt. Over the next several years, the total NIH budget is projected to grow in the range of 0-2% per year. Given "carve-outs" in the budget for special programs and given that existing grants have built in an inflation rate in salaries and other expenses of 3% or more, a flat NIH budget really means a contraction in funding for R01 grants, training grants, and other "traditional" grants that represent the lifeblood of this and other medical schools. In order to track the implications of these changes at URSMD, we began a research tracking system in September, 2003. Each quarter, Department Chairs receive a survey requesting information on grants that were submitted during the previous grant cycle, as well as the likelihood that they would be funded based on what is known about priority scores. This tracking system has provided us with more current information than had been available previously. To smooth out seasonal variation, a 4-quarter moving average is used. Over the past 4 quarters, for which data are unavailable, despite a flattening of the NIH budget, total research awards per quarter that were funded or were considered likely to be funded based on their priority score were as follows: $62.6 M, 62.3 M, 69.9 M, and 76.6 M.

Comment: An increase in NIH funding reflects an increase in the dollar value of applications submitted from $242 M to $310 M. Thus, even though the percent of federal URSMD grants that has been funded has declined over the past 4 quarters, from 33% to 27%, the increase in applications has led to a net increase in research funding.

D. Space

Data: Finally, we come to space, always the last frontier in an academic health center! With the exception of a few special circumstances, we have essentially run out of research space for both clinical and basic science investigation. Since 1997, we have completed a combination of new construction and major renovation that has led to the creation of 600,000 sq ft of new (Kornberg/MRBX) or "like new" upgraded space. In addition, during this past year we acquired an 85,000 sq ft laboratory research facility in Henrietta that will become the Cardiovascular Research Institute (CVRI).

Comment: During my first week as Dean in April, 2002, Dr. Jay Stein (then Senior Vice President for Health Affairs) took me on a tour of the Kornberg Building and MRBX. At that time, there was a substantial amount of empty research space in Kornberg and a sea of empty space in MRBX. I was clearly told that one of my main jobs was to ensure that these buildings would be filled with productive, funded investigators. Since then, working with Department Chairs and Center Directors, we have proceeded to implement their recruitment plans. As the process evolved, it became easier. That is, with the recruitment of each new scientist, collaborations were established with existing investigators and a critical mass/snowball effect occurred within and across scientific and medical disciplines. Despite the dark clouds at NIH, there is excitement in the air about research at URSMD. The fact that we have run out of space is actually a "good" kind of problem to have because of what it implies about the scope and vibrancy of the overall research enterprise. In Part 2 of this newsletter, I will devote a few paragraphs to the "Where are we heading?" part of the discussion about research space.

I hope you had a wonderful holiday season and wish you the best for the New Year ahead.

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry