Andrew Taylor Still was the founder of osteopathic medicine, and his namesake medical school – A.T. Still University – has long been one of the leaders in osteopathic medical education.
But last week, the A.T. Still School of Osteopathic Medicine in Arizona (ATSU-SOMA) announced a major change in their curriculum – one that highlights a serious problem facing medical education at large.
First, a brief background:
ATSU-SOMA used to have a ‘1+3’ curriculum. Students spent their first year in the classroom on the Mesa, AZ campus before being assigned to one of 16 community health centers (CHC) to continue their classroom education and begin getting clinical experience in their second year.
Only three of ATSU-SOMA’s CHCs were in Arizona – the rest were spread across the country, from Hawaii to New York. This allowed ATSU-SOMA to recruit students nationally: many pre-meds who might not have considered going to school in the desert Southwest gave ATSU-SOMA a look because of the possibility of spending the majority of their medical education close to home. (For their part, the community health centers hoped that many of these students would ultimately choose to practice there.)
But the CHCs weren’t just a recruiting tool.
They were also a convenient way to offload students from the main campus – and avoid expensive infrastructure upgrades as the school grew.
And in 2019, when ATSU-SOMA sought – and the Commission on Osteopathic College Accreditation (COCA) approved – an increase in class size from 107 to 162 students per year, it put increasing pressure on the school to find enough places to put its students when they left the Mesa campus after their first year.
Fissures began to develop in this system last year. ATSU-SOMA reduced the number of weekly clinical hours for second-year students from 8 to 4 – but still had to wind down their operations at four of the CHC’s. Efforts to recruit new sites were unsuccessful, so last week, ATSU-SOMA’s dean held a town hall meeting to announce that the school would be discontinuing the 1+3 model in favor of a traditional 2+2 curriculum in which students spend two years on the main campus before going to outside sites for their clinical rotations.
Obviously, most medical schools use a 2+2 model – so on the one hand, this is no big deal. COCA will almost certainly approve the change; current students and recruitment strategies will adjust; and business will go on as usual. But ATSU-SOMA will have to work through a few other problems – and some of them will be much harder to overcome.
Problem #1 is what to do with all the new second years on the main campus.
Soon, there will be 300+ medical students on a campus that was originally designed to hold around 60 students comfortably. Now, they’ll all be taking classes in a three-story building that also houses the physician assistant, athletic trainer, PT, and OT educational programs.
Problem #2 is how to repair relationships with the remaining faculty.
Listening to the Zoom, I was struck by how deeply disappointed many faculty were when they learned of this change. In the video below, one CHC faculty member poignantly asks why she would continue to accept ATSU-SOMA medical students for clerkships rather than students from local medical schools.
But Problem #3 is the biggie – how can ATSU-SOMA (and many other medical schools) maintain enough clinical training sites for their students in the future?
This isn’t a big problem for most MD-granting medical schools. They’re attached to a giant academic medical center capable of providing all the rotations their students their students need.
But many newer MD-granting schools – and nearly all DO-granting schools – lack these natural affiliations. Instead, they must develop contractual relationships with far-flung training sites.
Acquiring – and maintaining – clinical training sites has become a high stakes game of Risk for medical schools and their deans. Honestly, the most telling moment in the ATSU-SOMA town hall came when the dean was asked about third-year rotations. Her response was… something less than confident.
“Yes.”
Make no mistake, the fight for clinical training sites will be the major battleground for medical school competition for the foreseeable future.
Of course, MD and DO medical schools aren’t just competing with each other for clinical training sites. They’re also competing with Caribbean medical schools, NP/PA schools, etc. – many of which will pay handsomely for access to rotations. And to whatever extent schools of any type bid up the price for clinical sites and preceptors, it’s ultimately students (and their tuition) who will pay the bill.
Yet from the standpoint of society, there’s a bigger problem still: the cheapening of medical education.
When clinical sites become a seller’s market, a buyer can’t afford to be too choosy. Site and preceptor quality become less important than having someplace to send the students. Worse, any school that becomes too much of a stickler about transforming a fragmented shadowing experience into something more educationally meaningful risks losing the site to a less-nitpicky competitor. There will be a race to the bottom, down to the very bare minimum clinical experience that accrediting agencies will allow.
And folks, you can’t say I didn’t warn you.
Back in 2021, I got to speak to a group of osteopathic medical school deans on the biggest threats facing osteopathic medicine – and I highlighted this competition for clinical training sites, coupled with rapid expansion, as among the most serious.
I won’t say I told you so… at least not yet.
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