Educational Programs in US Medical Schools, 2002-2003

Medical schools continue to develop formal curricula that attempt to ensure that students will have acquired a body of knowledge, skills, attitudes, and values necessary for their future as physicians. While it has been argued that students also learn during informal interactions with their teachers and through the influences of the organizational culture,¹ it is in formal instructional offerings that the educational objectives of the medical school are addressed.

The medical curriculum in the first part of the 20th century was focused on the sciences basic to medicine (eg, anatomy, biochemistry, physiology, pathology, pharmacology, and bacteriology) and the core clinical disciplines (medicine, surgery, pediatrics, obstetrics, psychiatry).² By the latter part of the 20th century, many new disciplines and subject areas were being explicitly included in formal course offerings, in at least some medical schools. Some of these disciplines, eg, biostatistics,³ medicine and law,⁴ health economics,⁵ and medical informatics,⁶ are not based in traditional medical school departments.⁷ Medical schools also added structured teaching sessions covering topics such as complementary/alternative medicine⁸ and domestic/family violence,⁹ that were taught by more than 1 discipline.

These new subject areas were added to the curriculum because of a perceived need, as reflected, for example, in consensus documents by various professional groups.⁷ The standards for accreditation of educational programs leading to the MD degree also have changed to add requirements for education in some of the new content areas. For example, since 1990, standards have been added related to education in violence and abuse, cultural competence, and end-of-life care.¹⁰ Although surveys have assessed whether medical school curricula address specific subject areas, no studies have measured the amount of curriculum time devoted to many of the new subjects across all US medical schools.

This report reviews the status of medical education in 2002-2003, including data on faculty, medical school applicants and students, the medical curriculum, and the methods used to evaluate student learning. We have added, for the first time in this series, information on curriculum hours devoted to instruction in a number of new subject areas.

We also note that the Florida State University College of Medicine obtained provisional accreditation from the Liaison Committee on Medical Education (LCME) in October 2002; its charter class now is entering the third year of the curriculum. It is the first newly accredited MD-granting medical school in more than 20 years. For a list of the 126 medical schools in the United States conducting accredited programs as of September 1, 2003 (125 with full accreditation and 1 with provisional accreditation), see Article . For a list of the 16 Canadian medical programs accredited jointly by the LCME and the Committee on Accreditation of Canadian Medical Schools, see Article .

The data in this report were mainly derived from the 2002-2003 LCME Annual Medical School Questionnaire, which was sent to the deans of all 126 LCME-accredited US medical schools. There was a 100% response rate. Each completed questionnaire was reviewed upon receipt, and attempts were made to obtain missing data. Individual items for which the response was less than 100% are indicated below. Comparative data are presented from the 1997-1998 and 2001-2002 LCME Annual Medical School Questionnaires, each of which also had a 100% response rate.

Data on medical school applicants and entrants were obtained from the Association of American Medical Colleges (AAMC) Section on Student Services. The AAMC recently has changed how data on race and ethnicity of students are reported, making the data for the 2002 entering class not directly comparable with data from previous years. Therefore, only data on the percentage of underrepresented minority students in the entering class will be included. Other sources of data are cited in the text.

During 2002-2003, there were 109 526 full-time faculty members in LCME-accredited medical schools, a 13.2% increase from the 96 773 in 1997-1998 (Table 1). Of the total full-time faculty members in 2002-2003, 19 345 (18%) were in basic science departments, including pathology, and 90 181 (82%) were in clinical departments (Table 2). This represents a 12.1% increase in full-time basic science and a 13.5% increase in full-time clinical faculty members as compared with 1997-1998.

Of all full-time faculty members in basic science departments in 2002-2003, 36% held the rank of professor, 24% the rank of associate professor, 30% the rank of assistant professor, and 10% the rank of instructor/other. In clinical departments, a smaller proportion of faculty members were in senior ranks: 21% held the rank of professor; 22%, associate professor; 43%, assistant professor; and 14%, instructor/other. In summary, 60% of full-time faculty members in basic science departments held the ranks of professor or associate professor, as compared with 43% of faculty in clinical departments.

In addition to full-time faculty, there were 1631 part-time and 7116 volunteer faculty members in basic science departments, including pathology, and 18 198 part-time and 139 773 volunteer faculty members in clinical departments. In total, 274 906 individuals held faculty appointments in US medical schools during 2002-2003, as compared with 255 002 in 1997-1998 (a 7.8% increase).

One hundred fourteen schools supplied data on the racial/ethnic composition of their full-time faculty in 2002-2003. Of the 101 838 faculty members in these schools, 76 559 (75%) were white, 13 077 (12.8%) were Asian/Pacific Islander; 3128 (3.1%) were Hispanic, 3067 (3.0%) were African American, and 5864 (5.8%) were of unknown race/ethnicity. There were 30 915 women (30.4% of total full-time faculty members). In 1997-1998, 5.6% of total full-time faculty members were African American or Hispanic and 25% were women.^{11 - 12}

In summary, the number of medical school faculty members, both full-time and total, has increased substantially as compared with 5 years ago. In contrast, the proportion of full-time faculty from underrepresented minority groups remained about the same and the percentage of women increased slightly.

The number of applicants for the class entering in 2002 was 33 625, a 3.5% decline from the 34 860 applicants in 2001 and a 21.8% decrease from the 43 016 applicants in 1997 (Table 3). Of all applicants in 2002, 17 592 were accepted, a ratio of applicants to accepted applicants of 1.9:1.0 (Table 3). Of total applicants in 2002, 16 556 (49.2%) were women, as compared with 16 718 (48.0% of the total) in 2001 and 18 271 (42.5% of the total) in 1997 (Table 4).

The average premedical grade point average for new students entering in 2002 was 3.60, the same as in 2001. The mean grade point average of students entering in 1997 was 3.56.¹² Mean Medical College Admission Test scores for 2002 entrants were 9.5 in verbal reasoning, 10.0 in physical sciences, and 10.2 in biological sciences; these values are virtually unchanged from 2001¹³ and, in general, slightly increased from 1997.¹²

First-year enrollment in 2002-2003 was 17 120 (Table 3), of which 49.1% were women (Table 4) and 11.6% were members of underrepresented minority groups (ie, African American, American Indian/Alaskan Native, Native Hawaiian, Mexican American, or mainland Puerto Rican).¹³ First-year enrollment included 424 students (2.5% of the total) who were repeating the year. Of first-year students, an additional 270 (1.6%) were on a decompressed schedule, ie, taking fewer courses than typical.

During 2002-2003, there were a total of 66 677 students enrolled in US medical schools (Table 1), virtually identical to the number enrolled in 1997-1998. In 2002-2003, 31 290 (46.9%) of all enrolled students were women (Table 4). Of all students enrolled, 980 (1.5%) were repeating a year and 1196 (1.8%) were on a decompressed schedule.

A total of 365 students (0.5% of total enrollment) transferred into LCME-accredited medical schools during 2002-2003. Of these, 175 (48% of transfers) came from another LCME-accredited medical school in the United States or Canada, 50 (14%) from a non–LCME-accredited medical school, 9 (0.2%) from an osteopathic medical school, and 131 (36%) from a non–MD-granting graduate or professional degree program.

Final data from 2001-2002 allow an analysis of student progress and attrition. During 2001-2002, a total of 2523 students (3.8% of total students enrolled) were on a leave of absence. For the 15 640 students graduating in 2002, 13 402 (85.7%) had completed the curriculum in 4 years or less and 2238 (14.3%) in 5 years or longer. The increased time to graduation was due to additional study for enrichment or an additional degree (49.5% of students); academic difficulty, including decelerating or repeating a year (28.0%); leaves of absence for personal, financial, or health reasons (16.6%); and other reasons (5.9%).

Of all students enrolled during 2001-2002, 673 (1.0%) left their medical schools. Reasons included dismissal for academic reasons in 158 cases (24%); transfer to another medical school in 133 (20%); personal reasons, including financial and health in 122 (18%); withdrawal in poor academic standing in 117 (17%); career change or change in motivation for medicine in 88 (13%); and other reasons in 55 (8%).

Data from the AAMC indicate that the average total educational debt of indebted 2002 medical school graduates was $103 855. This is compared with an average debt of $99 089 for 2001 graduates and $80 462 for 1997 graduates.¹⁴

In summary, while the number of applicants to medical school has continued to decrease, there has not, on average, been a negative effect on the academic credentials of entering students. The level of student attrition is comparable with that from previous years. Student debt continues to increase.

During 2002-2003, in medical schools with 4-year educational programs, there were an average of 158 scheduled weeks in the curriculum: 38 in the first year, 37 in the second year, 47 in the third year, and 36 in the fourth. In the 105 schools that reported required hours of instruction, there were an average of 823 scheduled hours in the first year and 751 scheduled hours in the second year. In 1997-1998, there were an average of 155 scheduled weeks of instruction, with an average of 844 scheduled hours in the first year and 798 scheduled hours in the second year.¹²

As we noted earlier, schools continue to incorporate new subject areas into the medical school curriculum. In the 2002-2003 LCME Annual Medical School Questionnaire, schools were asked whether they included a number of these subjects as part of required courses or clerkships and, if so, the number of hours devoted to the subject. Data on instructional hours devoted to these subjects are presented in Table 5. The data indicate that most medical schools devote at least some curricular time to the subject areas, although there was considerable variation across schools in the amount of time devoted to most of the subjects. There are, however, no data on the specific courses or clerkships in which these subjects are taught, the instructional format used, or the department(s) responsible for the content.

The mean and modal numbers of weeks that students spent in required clerkships during the clinical years during 2002-2003 were ambulatory care, 5.2 (mode, 4); family medicine, 5.5 (mode, 4); internal medicine, 11.6 (mode, 12); neurology, 3.7 (mode, 4), obstetrics-gynecology, 6.7 (mode, 6); pediatrics, 7.3 (mode, 8); psychiatry, 6.0 (mode, 6); surgery, 8.3 (mode, 8), and surgical specialties, 4.5 (mode, 4). The mode, or most common clerkship length, is included, as the distribution of weeks alone may be skewed. For example, although the average number of weeks for obstetrics-gynecology clerkships was slightly less than 7, only 3 schools had a 7-week clerkship, while 75 had 6-week clerkships and 42 had 8-week clerkships.

Of the clerkships that were not required in all schools with a 4-year program, an ambulatory care clerkship was required in 48 schools, a family medicine clerkship in 112 schools, a neurology clerkship in 93 schools, and a clerkship in 1 or more surgical subspecialties in 69 schools. Some schools had both a family medicine and an ambulatory care clerkship. There were 72 schools that had a family medicine clerkship only, 8 schools that had an ambulatory care clerkship only, and 40 schools that included both as required clerkships.

The average amount of time spent in the ambulatory setting during required clinical clerkships was 93% in family medicine, 25% in internal medicine, 27% in neurology, 35% in obstetrics-gynecology, 42% in pediatrics, 27% in psychiatry, 21% in surgery, and 33% in the surgical subspecialties. As in previous years, the amount of time devoted to outpatient experiences within a given discipline varied among schools.

Many schools structure the third and fourth years as a continuum, so that time in required clerkships may be divided. In internal medicine, for example, 81 schools taught the internal medicine clerkship as a single third-year block, 4 schools had a single block that could be taken in either the third or fourth years, and 39 schools scheduled required clerkship time in both the third and fourth years. The average length of the fourth-year required clerkship in internal medicine was 4.4 (mode, 4) weeks. The clerkship in the surgical specialties was placed in the third year in 35 schools, the fourth year in 20 schools, and either the third or fourth years in 14 schools. A similar pattern was found for the neurology clerkship, which was located in the third year in 42 schools, in the fourth year in 29 schools, and in either the third or fourth years in 22 schools. For the 40 schools that had required clerkships in both ambulatory care and family medicine, the majority (23) placed ambulatory care in the fourth year and family medicine in the third. The clerkships both were in the third year in 14 schools, both in the fourth year in 1 school, and in some other configuration in 2 schools.

The fourth year remains the major period in the curriculum when students can spend time in elective experiences. In 2002-2003, there was a mean of 23 weeks of elective time in the fourth year. The amount of elective time was, however, variable among schools. Thirteen schools had less than 16 weeks of elective time, 73 had from 16 to 24 weeks, 34 had from 25 to 36 weeks, and 4 had more than 36 weeks.

All 4-year medical schools reported on the number and types of teaching hospitals used for inpatient experiences during required clinical clerkships. Schools used a total of 896 hospitals. Fifty-two schools used 82 university- or medical school–owned hospitals; 111 schools used 473 private, not-for-profit hospitals; 41 schools used 83 private, for-profit hospitals; 95 schools used 144 federal hospitals that are part of the Veterans Affairs or Department of Defense systems; and 68 schools used 114 state, county, or city hospitals. During 2002, there were 10 schools for which at least 1 hospital used for required clinical clerkships closed, merged, or was acquired, as compared with 35 schools in 1997.¹²

Medical schools continue to depend on the participation in the educational program of community physicians who serve as volunteer faculty. For example, in 75 schools (60%), community-based faculty worked with students in the ambulatory setting during the course that teaches basic clinical skills (eg, history taking and physical diagnosis) and in 78 schools (62%) community-based faculty participated in a course aimed at introducing students to medical practice. In 38 schools (30%), at least some volunteer faculty receive monetary payment for their participation in education, as compared with 44 schools (35%) providing monetary payment in 1997.

We previously presented data on the number of schools that required night call in various clerkships in the 2001-2002 year.¹⁵ Data for the 2002-2003 academic year show little change in mandatory night call in required clerkships: family medicine (20 schools), internal medicine (101 schools), obstetrics-gynecology (117 schools), pediatrics (102 schools), psychiatry (67 schools), and surgery (113 schools). Night call typically occurred every fourth night in 80 schools, every third night in 7 schools, and at some other frequency in 36 schools. In 2002-2003, 20 schools reported having a written policy on medical student work hours, as compared with 17 schools in 2001-2002.¹⁵

In summary, medical schools are including a number of topics in the curriculum that are either multidisciplinary or based in subject areas other than the traditional basic science and clinical disciplines. The average amount of time devoted to clerkships in the clinical disciplines had not changed from 1997-1998.¹²

During 2002-2003, 118 schools (94%) required students to take Step 1 and 106 required Step 2 of the United States Medical Licensing Examination; 106 (85%) required students to take both examinations. For advancement or graduation, a passing score on Step 1 was required by 107 schools (85%) and on Step 2 by 79 schools (63%). Seventy-nine schools (63%) required a passing score on both examinations for advancement or graduation, as compared with the 57 schools (46%) in 1997-1998.¹²

One hundred twenty-one schools used 1 or more of the National Board of Medical Examiners (NBME) subject tests to evaluate students' knowledge within courses or clerkships. During 2002-2003, the subject tests were used in the following basic science courses: biochemistry (31 schools), gross anatomy and embryology (27 schools), histology and cell biology (21 schools), microbiology (30 schools), neuroscience (19 schools), pathology (41 schools), pharmacology (30 schools), and physiology (29 schools). The use of NBME subject tests is more common in the clinical disciplines than in the basic sciences: clinical neurology (36 schools), family medicine (58 schools), medicine (111 schools), obstetrics-gynecology (109 schools), pediatrics (98 schools), psychiatry (99 schools), and surgery (110 schools).

In general, medical schools use written examinations (the NBME subject tests and/or internally prepared examinations) to evaluate students' knowledge in clerkships in the clinical disciplines: family medicine (110 schools), medicine (120 schools), neurology (88 schools), obstetrics-gynecology (120 schools), pediatrics (119 schools), psychiatry (120 schools), and surgery (120 schools).

The evaluation of students' clinical skills has traditionally been done by faculty members or residents observing students. For example, in 1997-1998, direct observation by faculty or residents of students performing a history and physical examination was used in required clinical clerkships as follows: family medicine (107 schools), internal medicine (110 schools), obstetrics-gynecology (104 schools), pediatrics (106 schools), psychiatry (105 schools), and surgery (101 schools). Observation by faculty members and/or residents remains a major form of clinical assessment in 2002-2003: family medicine (111 schools), medicine (121 schools), obstetrics-gynecology (118 schools), pediatrics (117 schools), psychiatry (121 schools), and surgery (115 schools).

In addition to observation of students in the context of their clerkship activities, many, but not all, schools use objective structured clinical examinations (OSCEs). The OSCEs test students' clinical skills through the use of multiple stations, often including standardized patients (SPs) trained to portray a clinical scenario in a standardized manner.

The LCME Annual Medical School Questionnaire for 2002-2003 was designed to gather comprehensive data on the use of OSCE/SP examinations in the basic course that teaches history taking and physical diagnosis skills (ie, the introductory skills course), in the required clinical clerkships, and in a final comprehensive clinical examination. Ninety-seven schools used 1 or more OSCE/SP examinations in the introductory skills course. One or more OSCE/SP examinations were used in the required clinical clerkships: family medicine (57 schools), medicine (56 schools), neurology (21 schools), obstetrics-gynecology (48 schools), pediatrics (47 schools), psychiatry (43 schools), and surgery (43 schools). In 82 schools, there was a third- or fourth-year comprehensive OSCE/SP examination outside the required clinical clerkships. These data represent a general increase in the use of OSCE/SP examinations as compared with 1997-1998. In that year, an OSCE/SP examination was used in the family medicine clerkship in 37 schools, in medicine in 36 schools, in obstetrics-gynecology in 22 schools, in pediatrics in 25 schools, in psychiatry in 20 schools, and in surgery in 18 schools. There was a final comprehensive OSCE/SP examination in 49 schools.¹²

There was, however, variable use of OSCE/SP examinations across the 124 schools with current 4-year programs during 2002-2003. During the clinical years, 12 schools (10%) used an OSCE/SP examination in only 1 clerkship, 19 (15%) in 2 or more clerkships, 13 (10%) only as a final comprehensive evaluation, 17 (14%) in 1 clerkship and a final comprehensive evaluation, 48 (39%) in 2 or more clerkships and a final comprehensive evaluation, and 15 (12%) in neither a clerkship nor a final comprehensive evaluation.

The structure of final comprehensive OSCE/SP examinations was also variable. The examination consisted of fewer than 5 stations in 3 schools, of 5 to 10 stations in 50 schools, of 11 to 15 stations in 18 schools, and of more than 15 stations in 9 schools (2 schools did not provide information). Of the 82 schools using a final comprehensive OSCE/SP examination, 53 (65%) required a passing grade for graduation. The general elements tested in the final OSCE/SP comprehensive evaluation were consistent across schools. Of the 82 schools, 80 evaluated history taking, 81 physical examination skills, 80 the ability to synthesize information to arrive at a diagnosis or management plan, and 76 the ability to communicate the diagnosis or findings to the patient.

Medical schools used a variety of types of facilities for teaching and evaluation activities that included SPs. Thirty-one schools used existing clinic space, 65 used a dedicated facility for SP sessions that was owned by the medical school or university, 15 used a dedicated facility for SP sessions that was owned by another institution or consortium, and 15 reported having no facilities for use with SPs.

Medical schools use a variety of means to evaluate the professional behavior of their students: observation by clinical faculty members (125 schools); observation by residents (119 schools); observation by basic science faculty members (95 schools); an OSCE with 1 or more professionalism stations (82 schools); comments from other health personnel, such as nurses (67 schools); and comments from patients (45 schools). Professionalism is an explicit component of the student's grade in 1 or more basic science courses in 35 schools (28%), in the course that teaches basic clinical skills in 83 schools (66%), and in 1 or more required clinical clerkships in 109 schools (87%).

In summary, while medical schools almost uniformly relied on written examinations to evaluate students' knowledge and on observation by faculty members and residents to assess clinical skills, the use of standardized methods of clinical evaluation (eg, OSCE/SP examinations) was much more variable across schools.

Women constitute less than one third of full-time medical school faculty members, and individuals from underrepresented minority groups (black and Hispanic) together account for about 6% of total faculty. Both women and underrepresented minority groups are less represented in the faculty than in the entering medical school class.

Interest in medicine as a career, as reflected in the number of applicants to medical school, has continued to decline. However, there are still almost 2 applicants for every position, and the students who are admitted have comparable academic credentials to those admitted in recent years. The increasing level of student debt continues to offer a challenge to medical schools and policy makers.

The medical school curriculum now includes a variety of subject areas that may not be placed solely in a single course or clerkship. Indeed, longitudinal teaching of some content areas, such as medical ethics or evidence-based medicine, across the 4-year curriculum would be beneficial. Currently, the amount of time devoted to many of these subject areas across schools is extremely variable. It is not known whether this is due to actual differences in the curriculum among schools or to the inability of some schools to identify where in the curriculum certain subjects are placed. The presence of a detailed curriculum database would allow schools to track the inclusion of specific content areas across the curriculum. Such a system also would help schools avoid gaps and unplanned redundancies in the curriculum. While most medical schools use written tests to assess student knowledge in the clinical disciplines, the presence of standardized performance assessment (ie, OSCE/SP examinations) is much more variable.