Stephen Abrahamson, Ph.D., Sc.D.

Professor Emeritus of Medical Education

University of Southern California School of Medicine
Los Angeles, CA 90033 U.S.A.


School:a place or institution for teaching and learning: specif., (a) an institution for training and instruction in some special field, skill, etc. . .

When one compares the medical school of 1995 with that of 1990, there is little difference. The same is true when comparing 1990 and 1985, and, indeed, in all such five-year comparisons, the differences are apparently inconsequential. However, when one compares the medical schools of 1995 and 1960, the differences are striking.

In 1960, a medical school fulfilled the definition above: a place for teaching medical students. Faculty members were employed to teach; the institution itself was designed and managed as a “place or institution for teaching and learning.? In 1995, however, a medical school may no longer be a school at all. It has become something else, reminiscent of the childhood riddle: “When is a door not a door??

When is a school not a school?

Answer:when it is a research institution.

The major purposes of a research institute are to discover new knowledge and to solve scientific problems through the development and application of basic sciences. While it is true that teaching may take place in such an institution, the purposes of the two (the school and the research institute) are not the same and may even be incompatible, since each has unique demands, requires a significant commitment of time, and expects appropriate talents, skills, and productivity from the faculty member.

Between 1960 and 1995, the sources of revenue for what we still call the medical school shifted from internal institutional money to primarily outside support. Well over half the operating budgets of basic-science departments is no longer institutional. Faculty members now spend less and less time on teaching medical students, and the school becomes less and less a place or institution for teaching and learning.

Interestingly enough, when one examines the time spent in teaching, even when combined with time spent on preparation for teaching and related activities for medical students-for only those faculty supported by the medical school-the teaching load is pitifully small. Few, if any, cost-accounting studies have been conducted, and to expose this condition is to risk ostracism at best and administrative hostility at worst. Middle managers in a medical school who are successful grantsmen and entrepreneurs (e.g., basic-science department chairs) do not tolerate criticism of a system that has rewarded them so well. Indeed, those who are successful in the system that has substituted the research-institute model for that of the school now control that system and guard their vested interests with zeal approaching ferocity.

When is a school not a school?

Answer:When it is a tertiary-care hospital.

As the basic support of medical schools has shifted from the university to outside funds, pressure to bring in more money has increased relentlessly. In the 1980s it became clear that health-care costs were rising and would continue to rise at a rate that exceeded the rate of inflation. Administrators of medical schools realized that performing high-cost procedures could bring a twofold return: money to support the medical school (and its parent university) and national prestige for pioneering work on the cutting edge of medicine.

To be successful in this arena, a school had to have physicians and surgeons capable of performing the procedures, and thus medical schools recruited and employed significant numbers of these highly talented and skilled practitioners and added them to the faculty. They do very little or no teaching of medical students, nor do they participate in the time-consuming activities associated with educational planning. They do, however, contribute to medical-school budget problems until revenues for the services catch up to the investment costs of adding them to the faculty.

The dominant force in the medical school, thus, began a shift from the basic-science entrepreneur to the clinical entrepreneur, all to the potential detriment of the education of medical students. Clinicians who are expected to bring in revenues to support themselves, the school, and the university do not spend time teaching medical students-it would be against their own best interests to do so.

When is a school not a school?

Answer:When it is an HMO.

Medical schools have learned that a tertiary-care facility cannot achieve and maintain the necessary flow of patients requiring the high-tech procedures without a sound primary-care referral system. This need has resulted in the establishment of still one more set of operations that potentially compete with the basic educational mission of the medical school.

The ethics of medical practice dictate that the patient come first. Thus, a physician faculty member whose major assignment is providing primary care in an HMO can devote little time to teaching medical students. Furthermore, when physician faculty members in a medical-school HMO attempt to involve themselves in the undergraduate teaching program, their beepers usually interrupt.

The inability of these physicians to devote significant time to the educational needs of the school also presents another problem for medical education: the primary care physicians cannot influence the education and training of medical students. Curriculum-planning committees are appointed with an eye toward balance among basic scientists, clinical specialists, and primary care physicians. But when faculty members representing this last point of view are among the missing at meeting after meeting of the curriculum committee (not by their own choice but because of the nature of their practices) the result may be a curriculum too heavily weighted with irrelevant science content and/or with specialty training.

When is school not a school?

Answer:When it is a medical school.

Whether it is the basic scientist engaged in entrepreneurial research, or the clinical entrepreneur engaged in high-cost, cutting-edge procedures, or the clinician engaged in primary care in the HMO setting, the “teachers” in the medical school are less and less engaged in teaching. Students as individuals are no longer known to the faculty; many faculty physicians seldom even see the medical students; and the students are no longer receiving sufficient small-group or one-to-one instruction.

Those now responsible for the educational mission of the medical school – to teach medical students-are graduate students in basic sciences, fellows in clinical specialties, and residents and interns. In the basic sciences, small group instruction in seminars and teaching labs has all but disappeared, with whole-class lectures remaining the teaching method. In the clinical disciplines, supervision of medical students by faculty has all but disappeared, with over-worked house officers bearing the major burden of providing what should be the one-on-one teaching that is the hallmark of excellence in helping students learn clinical medicine.

But the grim story does not end there. Those responsible for educational planning are faculty members whose careers are not affected by their performances as teachers: basic-science faculty whose existence depends on their ability to get grants and conduct research; super-specialist faculty, whose existence depends on their performing complex, revenue-generating procedures; and primary-care physicians, whose existence depends on their building a sizeable and successful EMO.

The education mission of a medical school-teaching young people who wish to become physicians-has gone from being the sine qua non for the school to being at the bottom of the priority list. Those in positions of power and control in the medical schools have central interests and concerns in conflict with the demands of high-quality undergraduate medical education. Until they recognize and acknowledge the problem, however, American medical education can expect no remedial action, and the answer to the question “When is a school not a school” will remain “When it is a medical school.?

1.Webster’s New World Dictionary of the American Language. 2nd college ed. New York: William Collins + New World Publishing, 1976.
2.Abrahamson S. The dominance of research in staffing of medical schools: time for a change? Lancet, September 25, 1993:342:1586-8.

This article was reprinted with permission from the January 1996 issue of Academic Medicine