PRIOR ACCREDITATION SURVEY, NOVEMBER 9-13, 1997
A summary of strengthsPROGRESS REPORT, AUGUST 5, 1998
The survey team also identified several areas of concern:
The survey team identified some areas that were in transition
SUMMARY OF TEAM FINDINGS AND CONCLUSIONS
1. Status of suit by basic science faculty members against the University.III. ADMINISTRATION
2. Current role of the Medical Faculty Assembly (MFA) in the governance of the medical school. IIV. EDUCATIONAL PROGRAM FOR THE M.D. DEGREE
3. Mechanisms by which non-administrative medical school faculty members have input into the decision making process of the medical school.
4. Evaluation of alleged deviations from statements in the Faculty Handbook related to medical school administration and grievance procedures.
5. Implementation of recommendations of the Blue Ribbon Task Force on Medical Education.V. MEDICAL STUDENTS
6. Process used for evaluation of courses and clerkships and the role of related committees and the Division of Medical Education.
7. Evaluation of students and process to provide feedback to students during clerkships.
8. Career guidance and MATCH results.
9. Over-enrollment of class entering in 1999.VI. RESOURCES FOR THE EDUCATIONAL PROGRAM
10. Tuition and fees and student debt including financial counseling.
11. Finances.
12. Status of agreement with LA County to provide faculty services at LAC+USC Medical Center.
13. Improvements in space for educational program.
14. Status of plans to build a replacement facility for the LAC+USC Hospital.
TO:
Liaison Committee on Medical Education
FROM: The ad hoc Survey Team
that visited Keck School of Medicine at the University of Southern California,
November 16-18, 1999
RE:
Survey Report
The ad hoc LCME survey team that visited Keck School of Medicine at the University of Southern California, November 16-18, 1999 is pleased to provide the following report of its findings and conclusions.
Respectfully,
Myron Genel, MD, Chair
Frank A. Simon, MD, Secretary
Linda H. Distelhorst, PhD, Member
LCME Accreditation Team Visiting
Keck School of Medicine
of the University of Southern California
[Limited Survey]
November 16 – 18, 1999
Stephen J. Ryan, MD – Vice President for Medical Care and Dean
Team Chair: Myron Genel, MD Pediatrics
Associate Dean, Government and Community Affairs
Yale University School of Medicine
333 Cedar Street
P.O. Box 208000
New Haven, CT 06520-8000
Phone: (203) 785-6019
Fax (203) 785-7208
E-mail: myron.genel@yale.edu
Team Secretary: Frank A. Simon, MD Pediatrics
Director, Division of Graduate Medical Education
American Medical Association
515 North State Street
Chicago, IL 60610
Phone: (312) 464-4395
Fax: (312) 464-5830
E-mail: frank_simon@ama-assn.org
Team Member: Linda H. Distlehorst, PhD Medical Education
Associate Dean for Education and Curriculum
Southern Illinois University
School of Medicine
P.O. Box 19230
Springfield, IL 62792-1217
Phone: (217) 782-7932
Fax: (217) 524-0192
E-mail: ldistlehorst@siumed.edu
A limited survey of Keck School of Medicine of the University of Southern California, Los Angeles, California, was conducted on November 16-18, 1999, by an ad hoc team representing the Liaison Committee on Medical Education (LCME). The composition of the survey team is given on an accompanying page.
The team expresses its appreciation to Dean Stephen J. Ryan, his staff, faculty, and students for their many courtesies and accommodations during the site visit. Dr. Clive R. Taylor, senior associate dean for educational affairs and his executive assistant, Linda Montellano deserve commendation for excellent visit arrangements and the timely provision of additional items of information as needs arose.
PRIOR ACCREDITATION SURVEY, NOVEMBER 9-13, 1997
The last accreditation survey was conducted on November 9-13, 1997, and resulted in continued full accreditation of the educational program leading to the MD degree. An initial progress report was requested for September 1998 concerning the outcomes of the "Blue Ribbon" Task Force on Medical Education and the status of renewal of the Professional Services Agreement with Los Angeles County. A limited survey was scheduled for the 1999-2000 academic year to address some areas of longstanding concern, issues related to the governance of the medical school and other concerns identified in the survey report.
A summary of strengths recorded at the time of the survey included:
Dean Stephen J. Ryan reported:
SUMMARY OF TEAM FINDINGS AND CONCLUSIONS
The leadership of the school and the faculty should be complimented on their efforts to develop an infrastructure to support substantial changes in the curriculum and to implement a system to improve advising and career guidance. Further the school has improved the educational facilities and is able to accommodate the one-time over-enrollment of students.
1. [Governance] Status of suit by basic science faculty members against the University. The lawsuit was settled in late 1998 following intensive negotiations. Nonetheless there remains an atmosphere of tension and dispute, at least on the part of some faculty, over adherence to the letter as well as the spirit of established policies and on efforts to develop more flexible compensation packages for medical school faculty. Based on the foregoing circumstances, this issue will need to be monitored.2. [Administration] Current role of the Medical Faculty Assembly (MFA) in the governance of the medical school. The 1998 Governance Document defines the MFA as a fact-finding, deliberative and consultative body that advises the dean and Executive Council on academic and faculty matters. Each department and major hospital affiliate with more than ten faculty elects representatives. It is, however, a relatively small body of 33 members that is led predominately by a cadre of engaged faculty. It is not clear to what extent the MFA truly speaks for a diverse faculty of some 1100 members, many of whom are preoccupied with their own professional and academic activities. In many respects, the MFA has become marginalized in the institution’s governance structure and now functions more as an irritant than as a partner in the school’s governance structure. The university-wide Academic Senate is the primary vehicle for faculty input on the issues of tenure, university contractual obligations and the adjudication of faculty grievances. While the specific role of the MFA is now defined, operational issues remain that should be monitored.
3. [Administration] Mechanisms by which non-administrative medical school faculty members have input into the decision making process of the medical school. The primary mechanism for input appears to be through the traditional departmental structure or via elected representatives to the MFA. Minutes of the MFA and the Executive Council are posted on the school’s web site and contain abundant information regarding operations of the medical school. The Governance Document also establishes a Finance Committee with at least ten faculty members as well as representatives from the student organizations and the MFA. Faculty-wide meetings are held twice yearly with an agenda determined by the MFA. Attendance generally runs 150-200 faculty. If desired, there are appropriate vehicles for faculty input.
4. [Administration] Evaluation of alleged deviations from statements in the Faculty Handbook related to medical school administration and grievance procedures. The LCME secretariat received communications alleging that the university was not following established grievance procedures and raised several issues relating to governance. The latter issues were similar to those reviewed and addressed under items 1-3 above. With respect to the grievance procedure, the survey team observes that responsibility resides within the university administration and that appropriate redress flows through the Academic Senate. Noting the two year delay in resolving this specific grievance and observing that final resolution has yet to occur, the survey team is nonetheless satisfied that no accreditation standard has been violated.
5. [Educational Program for the M.D. Degree] Implementation of recommendations of the Blue Ribbon Task Force on Medical Education. The Blue Ribbon Task Force submitted its plan for teaching and learning in medical education in April 1998. Implementation of this has begun. The administration of the curriculum has been centralized under the leadership of the deans for educational affairs. To achieve the goals of the Blue Ribbon Task Force, continued commitment of financial resources for development and implementation will be essential. Changes in educational methodology are proceeding, but remain a concern because their coordination as part of an overarching curricular vision appears to be disjointed.
6. [Educational Program for the M.D. Degree] Process used for evaluation of courses and clerkships and the role of related committees and the Division of Medical Education. There are well-defined processes for the regular review of courses in each year of the curriculum. Students provide input via computer-based questionnaires at the conclusion of each course. This information is reported directly to the Years I/II and Years III/IV Curriculum Committees as well as the Educational Policy Committee and the department chairs. This is no longer a continuing concern.
7. [Educational Program for the M.D. Degree] Evaluation of students and process to provide feedback to students during clerkships. The "Educational Practice Guidelines for Required Clerkships" established by the Education Policy Committee along with the regularly scheduled formal reviews of each required clerkship have addressed the concern of providing students with mid-rotation evaluations. The timely reporting of final clerkship evaluations is also included in the guidelines. Reporting of the achievement of the standards was not consistent among the various constituencies. Greater attention must be paid to the application of these guidelines in order to resolve the issues related to the timely evaluation of students during and at the end of required clerkships. Compliance will need to be monitored to determine the effective resolution of the problems.
8. [Educational Program for the M.D. Degree] Career guidance and MATCH results. The school has developed a systematic approach to career guidance and advisement of students about their elective programs. The existing counseling system is an enhancement of some programs that were in place in November 1997 as well as the addition of new offerings. Feedback from the students suggested that the enhanced advising programs had not been operating long enough to demonstrate improvement in career guidance. The effectiveness of the new programs will have to be evaluated over time. The team members agreed that continued monitoring of these programs would be necessary.
9. [Medical Students] Over-enrollment of class entering in 1999. The increase in class size for the entering class in 1999 was the result of an unexpectedly high yield of matriculants from the initial group of acceptances. No individuals were selected from the alternate list. There are plans in place to adjust the acceptance process for 2000 that should effectively compensate for the higher yield. Increased tuition revenue from the larger class size is being used to modify the educational environment to avoid creating new stresses. The adjustments made to manage the over-enrollment appear to be working well. The survey team concluded that this single episode of an increased class size is not a continuing concern.
10. [Medical Students] Tuition and fees and student debt including financial counseling. Since the last site visit, tuition and fees have increased. Student debt is the single most important issue among the student leadership. In the most recent year, the students were able to introduce a phased tuition increase in part through their representation on the finance committee. The survey team shares the students’ concern regarding their excessive debt burden. Escalating tuition and fee increases remain a concern.
11. [Resources for the Educational Program] Finances. A careful review of the draft financial questionnaire for FY 1998-99 and discussions with the chair of the Finance Committee and the vice-president for finance resulted in the straightforward reconciliation of financial data over time and from different sources. Although uncertainty remains regarding the agreement with LA County – County Professional Services Agreement (CPSA), a failure to renew the contract would have a minimal net impact on the overall budget of the school but could affect the educational programs. The issue of salary support for basic science faculty members has been resolved. The medical school is currently financially stable with increasing revenues and surpluses. Thus, at the present time, this is no longer a concern.
12. [Resources for the Educational Program] Status of agreement with LA County to provide faculty services at LAC+USC Medical Center. The contract for professional services still provides substantial income to the medical school and a large portion of salaries paid to clinical faculty. For the past two years the contract has been extended while terms have been renegotiated. As some issues are resolved, new ones arise. The county’s obligation under California Proposition A to demonstrate that the current contract is more efficient than providing services directly now complicates the process. While negotiations continue, faculty contracts now stipulate that the portion of faculty salary derived from the CPSA contract is not guaranteed. Administration officials remain confident that a satisfactory arrangement with the County will result. Nonetheless the uncertainty of the outcome and the overall impact on the school’s educational and clinical programs requires close monitoring.
13. [Resources for the Educational Program] Improvements in space for educational program. Lecture halls, multidisciplinary laboratories, and the gross anatomy laboratory have been remodeled or refurnished to improve the environment for the medical education programs as well as accommodate for the increased number of students in the first year. Identifying small group space continues to be a need.
14. [Resources for the Educational Program] Status of plans to build a replacement facility for the LAC+USC Hospital. After many years of effort, plans for construction of a replacement facility for the LAC+USC hospital are moving forward with expected completion by 2005. The LA County Board of Supervisors has approved construction of a 600-bed hospital. Substantial plans have been developed and were shared with the survey team. The Board of Supervisors has also approved construction of a 60-150-bed facility in the East Los Angeles/San Gabriel Valley area, although financing and staffing have yet to be defined. Continuing monitoring will be required.
1. Status of suit by basic science faculty members against the University. The suit filed by 23 members of the medical school’s basic science faculty stemmed from actions taken in June 1995 to alter compensation for tenured basic science faculty from a 12 month to a 9 month academic schedule, in effect reducing compensation by 25% for those faculty unable to cover the remainder via external funding or with departmental resources. While never fully implemented and in effect reversed shortly thereafter, the suit was based on alleged violation of University policies relating to issuance of faculty contracts which, according the University’s faculty handbook, are to be issued annually by the University Provost’s Office for tenured and tenure track faculty or by the school’s dean for other faculty. Additional issues related to allegations of age discrimination and the economic implications of tenure. The suit was settled in September 1998 after intensive negotiations utilizing a professional academic mediator and finalized on December 21, 1998.III. ADMINISTRATIONNotwithstanding the legal settlement, there remains an atmosphere of tension and dispute, at least on the part of some faculty, over adherence to the letter as well as the spirit of established policies and on efforts to develop more flexible compensation packages for medical school faculty. Among the more contentious issues is the precise meaning of tenure for clinical faculty, which is under consideration by the university-wide Academic Senate, and supplemental compensation to faculty for teaching curriculum development, and administrative responsibilities.
Survey team members were provided a letter written by an executive committee representing the basic science litigants alleging that the University "has not honored" the spirit nor abided by the text of the settlement agreement (included in the Appendix). It is noteworthy that this letter was posted on the web site of the Medical Faculty Assembly shortly thereafter. Subsequent to receiving the letter, the survey team met with the senior associate dean for faculty affairs, and the attorney who represented the University on this case. The team was informed that great care had been taken in reviewing the salaries and continuing status of the basic science faculty. Although there have been differences among departments as to whether the chairs solicited comments via a formal committee review process or informally from the faculty, the process appears to have been handled quite carefully and fairly. Survey team members were also informed that signed annual contracts were returned from all but a few of the original plaintiffs who remain at the medical school. Based on the foregoing circumstances, this issue will need to be monitored.
2. Current role of the Medical Faculty Assembly (MFA) in the governance of the medical school. Issues relating to faculty governance, engagement of the faculty in the decision making process and specifically the role of the MFA were raised during the prior full survey in November l997. A revised Governance Document for the medical school was developed after that visit with input from the MFA and approved by the University’s Board of Trustees the following November. The Governance Document designates the composition and responsibilities of the school’s Executive Council, the MFA and the medical school’s administration. The MFA is defined as a fact-finding, deliberative and consultative body, which advises the dean and Executive Council on academic and faculty matters. Each department and major hospital affiliate with ten or more full-time faculty is represented through elected representatives who serve two-year terms and are eligible for a second consecutive term. The MFA meets monthly and disseminates minutes and other materials widely via its web site and e-mail.IV. EDUCATIONAL PROGRAM FOR THE M.D. DEGREEThe survey team met with leadership of the MFA as well as other faculty representatives. An extensive communication that outlines actions and positions of the MFA on a variety of issues was provided to the survey team and is included in the appendix to this report. The MFA is a relatively small body of 33 members that is led predominately by a cadre of engaged faculty. At least as reflected in the MFA’s posted minutes, many department representatives are unable to regularly attend meetings, which are held Tuesday at noon. It is not clear to what extent the MFA truly speaks for a diverse faculty of some 1100 members, many of who are preoccupied with their own professional and academic activities. In many respects, the MFA has become marginalized in the institution’s governance structure and now functions more as an irritant than as a partner in the school’s administration. The university-wide Academic Senate, which has six representatives from the medical school, including the MFA president-elect, secretary, and treasurer, is the primary vehicle for faculty input on the issues of tenure and university contractual obligations and the adjudication of faculty grievances. While the specific role of the MFA is now defined, operational issues in fulfilling that role remain and should be monitored.
3. Mechanisms by which non-administrative medical school faculty members have input into the decision making process of the medical school. As described in the database, there are a variety of mechanisms by which faculty members can influence the decision making processes of the medical school. Faculty members have direct access to the dean and the senior associate dean for faculty affairs. Each department elects representatives and alternate representatives to the MFA, described above. The Governance Document provides that a special meeting of the school’s Executive Council to consider a specific issue or a special meeting of the general faculty can be scheduled on petition of 20 faculty members. In addition, faculty may attend any meeting of the Executive Council upon notifying the dean or the council secretary at least 24 hours in advance and can request permission to address the Council regarding issues of concern. The Governance Document also establishes a Finance Committee with at least ten faculty members as well as representatives from the student organization and MFA. This committee advises the dean on budgetary matters. Based on the survey team’s meeting with the committee chair, school’s CFO and two committee members, one of them a medical student, the entire process appears to be fairly open.
For the most part, the primary mechanism for faculty input appears to be through the traditional departmental structure, specifically the department chairs to the Executive Council or via elected representatives to the MFA. Minutes of both are posted on the school’s web site within a few weeks and contain abundant information regarding operations of the medical school. Faculty-wide meetings are held twice yearly with an agenda determined by the MFA. Attendance generally runs 150-200 faculty. Finally, there is opportunity for input through departmental faculty meetings. It appears that faculty members have as much input as they desire and those surveyed during the visit seemed comfortable with the opportunities for involvement on issues of institutional or personal significance.
4. Evaluation of alleged deviations from statements in the Faculty Handbook related to medical school administration and grievance procedures. The LCME secretariat received two communications from a professor of (department deleted). In one document, dated September 1, l999, this individual alleged that the university was not following established grievance procedures in providing a timely resolution to a grievance filed on November 18, l997. Although a hearing was held on October 20, l998 with a report of the Hearing Board issued shortly thereafter, a decision on the hearing board’s recommendations had not yet been received.
The Faculty Handbook states, "the President will consider the record and make a decision as promptly as possible, generally within 30 days of…receiving the grievance panel’s recommendation." The survey team reviewed the complaint with the senior associate dean for faculty affairs who noted that the president of the university had concluded that the Hearing Board had exceeded its authority and asked the Hearing Board to resubmit their decision in two reports; one dealing with grievable issues and university obligations to tenured faculty and the second on "other" issues. The survey team was not informed if these reports have been submitted or whether a decision has been reached.
The second communication, dated October 4, l999, raised several issues relating to governance, all reviewed and addressed under items 1-3 above. With respect to the specific grievance procedure, the survey team observes that responsibility resides within the central university administration and that appropriate redress flows through the Academic Senate. However, the survey team notes with some concern that there has been a two-year delay in resolving this grievance and that final resolution has yet to occur. Notwithstanding this concern, the survey team is satisfied that no accreditation standard has been violated.
5. Implementation of recommendations of the Blue Ribbon Task Force on Medical Education. At the time of the last site visit in November 1997, implementation of a major curriculum change that was supported by the faculty had not begun because of budgetary constraints. Of further concern was the absence of an effective system to coordinate and review the curriculum, including changes in courses offered during the first two years. Student concerns included excessive time spent in lectures and heavy reading assignments. A Blue Ribbon Task Force on Medical Education had been appointed in early 1997 to review the curriculum, focusing on educational methodology, student evaluation and clinical relevance. The report submitted in April 1998 to the Educational Policy Committee serves as the blueprint for the emerging curriculum to be implemented in 2001.The administration of the curriculum has been reorganized under the senior associate dean for educational affairs and is the direct responsibility of the associate dean for curriculum. Two assistant deans have been appointed to oversee basic science and clinical science education. In addition, a director and assistant director have been added to the office administration. These faculty administrators constitute an operations committee which meets weekly for the purposes of strategic planning and implementation of the educational programs. Because of its membership, this operations group interfaces with all of the curriculum committees, receiving assignments and providing progress reports regarding planning and implementation activities.
A Curriculum Revision Implementation Planning Committee has been appointed and is using a continuous one-year plan to revise the curriculum over a two-year period. The timeline for implementation began in August 1999. The revised curriculum schedule begins in the first year with core principles of health and disease followed by organ systems – function/dysfunction continuing into the second year and ending with an integrated case study approach to health and disease. Introduction to Clinical Medicine continues through both years of the curriculum with cadaver dissection scheduled for the beginning of the first year. Restrictions on supplemental and handout material as well as the continuing decrease in lecture hours will be managed with the implementation of the curriculum revision planned for 2001-2002. A website for faculty lectures, their attendant lecture notes, and any relevant visual materials such as photographs of gross materials, histological slides, and electrocardiogram tracings has already been developed. Students speak highly of these resources.
Following careful consideration of the School’s educational objectives, the existing curriculum, the previous proposal for curriculum reform, other medical school curricula, relevant published literature, and the results of a student survey, a subcommittee of the Years I/II Curriculum Committee developed the specific proposal for the first two years of the curriculum. Their recommendations complemented the work of the implementation committee. The course work was developed to promote increased clinical relevance, increased use of computer-aided instruction, and decreased hours of traditional lectures. A similar review by the Years III/IV Curriculum Committee is scheduled to begin in February 2000.
Congruent with these recommendations, a case-based education committee composed of generalist physicians and basic science faculty representatives from each year, as well as students has been assembled. This committee reports to the Educational Policy Committee. Since the creation of the committee, a standard case format and protocol for case development has been developed along with the completion of 60 cases included in an electronic database. In addition a master list of approximately 200 cases that students should encounter over their four-year educational program has been generated. These cases were derived from national databases developed by the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control, and the National Center for Health Statistics and further refined by the School’s faculty.
A case-based education coordinator is working with the committee to achieve its goals and is assisting faculty with implementation of the case-based curriculum as well as relevant research projects. Although the intent is that these cases and their learning objectives will formulate the basis for the core clinical learning objectives for general curriculum content and the relevant curriculum committees will oversee their distribution, it is not completely clear what mechanisms will be used to ensure that all cases are used in the most appropriate way for the basic and clinical sciences.
Although there is clear evidence of progress being made in changing educational methodology, at this time the coordination of these efforts as part of an overarching curricular vision appears to be disjointed. Activities of the various committees are proceeding independently. In particular, the integration of the case-based curriculum into the overall framework was not readily apparent. Thus, the implementation of the revisions in the curriculum will need to be monitored.
6. Process used for evaluation of courses and clerkships and the role of related committees and the Division of Medical Education.. There are well-defined processes for the regular review of courses in each year of the curriculum. The system for the evaluation of courses and clerkships includes several components. The results are reported directly to the Years I/II and Years III/IV Curriculum Committees as well as the Educational Policy Committee and the department chairs.
The Guidelines for Year I and II System Chairs that was revised and approved in June 1998 and is included in the appendix provides for a subcommittee for each organ system to review the previous year’s offering approximately three months prior to the scheduled delivery of that system. The chairs create the subcommittees with representative faculty and students from each of the two years. The organ system schedule created as a result of the review must be submitted to the Years I/II Basic Sciences Curriculum Committee for review and approval at least two months prior to the start of the system. The chairs are also responsible for the review of instructional handouts and examination questions. Medical students are asked to complete on-line evaluations of all course lectures and lecturers, laboratory instructors, handouts, and other assigned readings including textbooks. Some departments ask their faculty to evaluate the department’s lectures and laboratory sessions through a departmental peer review process.
The relevant curriculum committee and the responsible faculty then use the results of these reviews to prepare for the next academic year.
The evaluation of clerkships in Year III/IV is based on the Educational Practice Guidelines for Required Clerkships while the system for review is outlined in the Process for Required Clerkship Review Year III Committee. Both of these documents are included in the appendix. The review process requires the appointment of a review subcommittee and the completion of a detailed self-study document by the clerkship director and/or coordinator. The members of the subcommittee review this material and prepare a report that includes a description of the clerkship’s structure, its strengths and weaknesses, and make recommendations to the clerkship director and the department chair. The report is presented to the Years III/IV Curriculum Committee for discussion and a final report is sent to the department chair and the senior associated dean for academic affairs. Six months to one year after the final report has been presented the clerkship director provides an update to the Curriculum Committee to address the implementation of changes that were negotiated as a result of this process. An example of a completed self-study was provided to the survey team.
Based on the clear formulation and evidence of application of guidelines for the evaluation of courses and clerkships, the survey team agreed that this is no longer a continuing concern.
7. Evaluation of students and process to provide feedback to students during clerkships. The Education Policy Committee has established "Educational Practice Guidelines for Required Clerkships" that includes in the section on student assessment the statement that "Students with unsatisfactory performance [be] provided with feedback at mid-rotation and Dean of Student Affairs [be] notified." Compliance with this guideline is investigated during the formal review of each required clerkship, scheduled about every two or three years. In completing the self-study outline, the clerkship director must indicate "How are students given feedback about their progress during the clerkship?" and "Are students given feedback in a timely manner?" Student input is used to confirm this information.
The report in the database indicated that the reviews of the required clerkships demonstrated that nearly all of the required clerkships had mechanisms in place to provide routine feedback to the students. While this is accomplished most often by the attending on service, General Surgery uses a standardized patient Observed Standard Clinical Assessment (OSCA) mid-rotation to help identify problem areas in clinical skills. The rotations with the greatest difficulty in meeting the standard are those of only three weeks duration or those made up of two different three-week segments. This problem was reinforced in the example of the review of the pediatric clerkship in which it was stated that the structure of the outpatient segment was "not conducive to significant feedback." It was noted that informal feedback was provided in this setting through regular interactions with attending physicians and formal feedback was provided by the end of the second week of the inpatient portion by nurse educators using final evaluation forms to measure minimal performance standards. The students indicated that compliance with this guideline is not uniform and that mid-rotation feedback does not occur on some rotations.
The guidelines cited above also require that "Clerkship evaluations [be] submitted to the Dean’s Office within six weeks of the end of the clerkship." The delay in the receipt of final clerkship evaluations was noted as a concern during the previous full survey. Reports from administrators in the Office of Student Affairs indicated that final grades are being provided for required clerkships on a timelier basis and that delays in the reporting of final evaluations were sporadic and related to variability in the timeliness of feedback from faculty and residents. Although, it was stated that students no longer raise this as a concern, the students related that the reporting of final grades frequently were delayed well beyond the six-week limit.
The team felt that the concerns noted in the survey of November 1997 have been addressed through the development of guidelines for the required clerkships and the implementation of regularly scheduled reviews of those clerkships. However, greater attention must be paid to the application of these guidelines in order to resolve the issues related to the timely evaluation of students during and at the end of required clerkships. Compliance will need to be monitored to determine the effective resolution of the problems related to the evaluation of students.
8. Career guidance and MATCH results. The school has developed a more systematic approach to career guidance and advisement of students about their elective program since the last full survey in November 1997. The existing counseling system is an enhancement of some programs that were in place in 1997 as well as the addition of new offerings.
The pre-clinical faculty advisor program has been expanded to include both first and second-year students in groups of 13-14. An orientation program was presented to assist the faculty serving as pre-clinical advisors in meeting their responsibilities. The 26 pre-clinical advisors are required to meet with their students at least four times during the school year. The students must complete a self-assessment form for each of the required meetings. These forms collect information on academic progress and quality of life issues and on alternate meetings include questions of professional development. The advising system is designed to be more proactive than in the past and has been most helpful to the first-year students.
A formal clinical faculty advising program was introduced in 1998. Students are asked to identify a department and if possible, to request a specific advisor. The chairs identified key individuals from each of the clinical departments to serve as core clinical faculty advisors. The department chairs were then responsible for assigning students to advisors. All students who are undecided about a specialty are assigned by Student Affairs to a faculty member selected from a special group of advisors and are directed to various resources for career guidance. The students continue with their same advisor through the fourth year. Advisors’ signatures are required on all selective/elective clerkship petitions. This is being further expanded to include second-year students. A section of the Junior/Senior Handbook, included in the appendix, provides counseling and advisement information.
Other programs for career guidance have been introduced for the students. The Glaxo Wellcome Pathways Program for third and fourth-year students was first offered in 1998 and the new MedCAREERS program of the AAMC became available on September 16, 1999 for first-year students.
Feedback from the students suggested that the enhanced advising programs had not been operating long enough to demonstrate improvement in career guidance. The effectiveness of the new programs will have to be evaluated over time. The team members agreed that continued monitoring of these programs would be necessary.
The school reported that 151 students or 96% of the class participated in the NRMP in 1999 with 145 students or 96% matched. Five of the unmatched students or 83% secured positions within 24 hours. These figures compare favorably with those of previous three years in which 5%-10% of the students were unmatched. The following list of specialties for the class graduating in 1999 is compared to national figures.
| Specialty Matched |
(nearest %) |
Students |
| Internal Medicine |
|
|
| Family Medicine |
|
|
| Surgery |
|
|
| Pediatrics |
|
|
| Emergency Medicine |
|
|
| Obstetrics-gynecology |
|
|
| Orthopedic Surgery |
|
|
| Urology |
|
|
| Neurology |
|
|
| Neurosurgery |
|
|
| Ophthalmology |
|
|
9. Over-enrollment of class entering in 1999. The Admissions Office was restructured in the fall of 1998 with the appointment of a new associate dean for admissions. The admissions process was improved with the development of a more efficient and responsive system and progress was made with respect to minority admissions. Decisions on applicant files were completed prior to May 15, 1999. A similar number of acceptances were offered as for the previous year. However, the yield for the class entering in 1999 was approximately 51% compared to 35% the previous year. No offers were made from the alternate list in 1999. An offer to defer admission for one year made to the accepted students was agreed to by 13 students thus decreasing the entering class to 174. Charts comparing minority student matriculation, admission offers and enrollment and the academic statistics for enrolled students for the last two years are included in the appendix.VI. RESOURCES FOR THE EDUCATIONAL PROGRAMA review of the admissions process by the school suggested that the increase in the yield rate could be due to the increased focus on recruitment. The interview day was redesigned; staff were more responsive to applicant queries and highly desirable applicants were recruited proactively. The school plans to adjust the acceptance process for 2000 to compensate for the higher yield and will offer only 250 initial acceptances instead of the historical 364-368 while making greater use of their alternate list.
Plans for accommodations for the larger class size are based on a budget analysis that is included in the appendix. The over-enrollment of 24 students represents an anticipated revenue increase to the school of medicine of $677,586. This added revenue would provide funding for additional faculty for small group teaching, facilities expenses and specific course expenses with $276,671 available for year-end teaching bonuses. Many students use a new overflow lecture room that is equipped with interactive television monitoring in preference to the standard room and all lectures are videotaped. In gross anatomy, dissection groups have been increased from four/five to six with students rotating off dissection groups for supplemental instruction. Although not ideal, this solution is considered acceptable by the faculty and students. The multidisciplinary laboratories have been modified effectively to manage the larger class size. The most pressing problem is the availability of rooms for instruction in Introduction to Clinical Medicine. This is not a new problem but is exacerbated by the increase in class size. Students are assigned to rooms in a building that is off campus. Current first-year students are comfortable with the teaching circumstances.
It is anticipated that the clinical clerkships will be able to accommodate the larger class without difficulty based on the school’s history over the last three years of accepting between eight and 15 transfer students into the third year. This practice was intended to increase the number of students in the third-year class to a total of 165-170. The adjustments to manage the over-enrollment appear to be adequate. This single episode of an increased class size is not a continuing concern.
10. Tuition and fees and student debt including financial counseling. At the 1997 site visit, concern was expressed regarding escalating tuition and fees for the medical school as well as the average level of debt above $105,000. Of equal concern was that about 30% of indebted students graduated with debts of $150,000 or greater.
Since the last site visit, tuition and fees have continued to increase each year, with the greatest portion of that being in tuition and a much smaller contribution from student health fees. For the past two years, based on a curricular requirement, a $2800 allowance for a computer is available in calculating financial aid for students. This does not represent a direct charge to students. The average overall debt and the percentage of students with debt above $150,000 have increased. Students with debt graduating in 1999 had an average debt of $116,000 with about 36% having a debt of $150,000 or greater. Comparison with other private medical schools reveals that students at this institution are graduating with an average debt that is above the national mean.
In 1998-99, the tuition and fees at the School of Medicine were ranked fifth highest for private medical schools in the US. The University authorized a 5.9% increase in tuition for all students for the 1999-2000 academic year. The students were able to introduce a phased tuition increase with a differential rate based on class year in part through their representation on the finance committee. The University accepted the plan forwarded by the Finance Committee of the medical school. Thus, this year, fourth year students had a 2% increase, third and second year students had a 4% increase, and first year students had the full 5.9% increase.
Students have been very vocal about limiting tuition increases and provided the survey team with a carefully researched and well-reasoned case for such action. The student leadership is to be complimented on their professional presentation. Unfortunately, since it is the university, not the School of Medicine that is mandating the tuition increases; the students’ ability to succeed in capping tuition is limited. The medical students strongly hold that any ongoing increases in tuition should be committed entirely to medical student education at the Keck School of Medicine and should not be used for other purposes within the Medical School or University. In spite of the concern expressed by students, the tuition and fee levels do not appear to have an appreciable effect on student enrollment.
From the time that students enter into the admissions process, they are provided information regarding the projected debt level and how to manage this situation. There are multiple opportunities for debt counseling. A mandatory session is held when students enter medical school, and they are encouraged to meet with a financial aid counselor to develop a financial plan.
These counselors are available to assist students at any time during the undergraduate course of study. Students are also provided information regarding other debt management resources such as repayment calculators on the Web. On graduation, students are given a loan repayment packet to assist them. To date, the default rate for federal loans is very low at approximately 1% and students do not appear to be making career choices based on their level of debt.
At present, scholarship funds for medical students are limited. However, the Development Office is working to create a $20 million endowment to enhance the available funds. Due to their efforts, an additional $379,000 was awarded to students who matriculated in the 1998-99 academic year. A Scholarship Committee under the leadership of the associate dean for student affairs awarded these funds. To further increase scholarship funding, donor programs are being developed to integrate cash components with planned giving and to target the alumni.
The survey team shares the student concern regarding their excessive debt burden. The continued escalation of tuition and increases in fees remain a concern at this time.
11. Finances. The draft of the Annual LCME Part I-A Questionnaire, Annual Financial Questionnaire, for Fiscal Year 1998-99 is included in the appendix. A comparison of this data with that included in the November 1997 survey report reveals a substantial absolute and relative increase in funding from grants and contracts and an absolute increase but relative decrease in funding from practice plans and hospitals. The relative contribution from hospitals to the revenue of the school continues to represent a disproportionate share compared to other private medical schools. The surplus of revenues over expenses that has increased from approximately $12 million to $21.5 million remains as revenue from and on behalf of the affiliated institutions and the practice plan. Thus the surpluses do not represent funds available to the medical school but instead reside in affiliate accounts. Each department has a separate 501(c) (3) practice plan. Funding from the LAC+USC Medical Center to the medical school has been stable since FY96/97 at approximately $67 million.Total grant funding and indirect cost recovery have increased approximately $61 million since 1996-97 with the greatest increases occurring in revenue not recorded in medical school accounts. This increase is principally the result of revenues from the affiliated National Childhood Cancer Foundation that had not been included in previous calculations. An issue raised in the November 1997 report concerned the assessed indirect expenses by the University that exceeded the indirect costs generated by the medical school. Although this practice continues, it is based on a formula that includes a base assessment unrelated to grant funding and a variable component that is determined by grant expenditures recorded in the medical school accounts. The negative balance is less than $1 million.
Within the overall budget, there is a budget for current unrestricted funds that provides support for administration, departments, institutes, research, facilities, development, and indirect cost assessments. The preliminary figures for FY99 show a steady increase in the amount in the fund since FY97 to $64.2 million.
At the end of July 1999 the University of Southern California announced a $110 million grant to the medical school from the W. M. Keck Foundation. Under the terms of the gift, the medical school was renamed the Keck School of Medicine of the University of Southern California and a board of overseers was created with equal representation from the foundation and the university. Notification of the name change is included in the appendix. The foundation will make cash payments to the university over a period of no more than 12 years and the university must raise $330 million in matching funds during a seven-year period. The president of the university is committed to a $600 million development program for the medical school that includes the Keck gift.
The following table compares the information in the annual financial questionnaire for FY1998-99 with summary data for FY1997-98 as reported in Krakower, Williams, and Jones Review of US Medical School Finances 1997-1998. JAMA, 282(1999):847-854.
Revenue Sources ($ in Millions)
| Source |
|
Keck School of Medicine |
(all private) |
| Tuition and fees (total) |
|
|
|
| State appropriation |
|
|
|
| University |
|
|
|
| Grants/contracts (direct) |
|
|
|
| Indirect cost recoveries |
|
|
|
| Practice plans |
|
|
|
| Gifts and endowment |
|
|
|
| Hospitals |
|
|
|
| Total revenue |
|
The concerns regarding the financial condition of the school at the November 1997 survey related to the uncertainty of the agreement with LA County (County Professional Services Agreement CPSA) and the problem of providing 12 months salary support for basic science faculty members. While the renewal of the CPSA has not been resolved, a failure to do so would result in the return of faculty to County employment without a disruption in service or availability for teaching and minimal net impact on the budget. The salary support for basic science faculty members has been resolved.A careful review of the draft financial questionnaire for FY 1998-99 and discussions with the chair of the Finance Committee and the vice-president for finance resulted in the straightforward reconciliation of financial data over time and from different sources. The medical school is currently financially stable with increasing revenues and surpluses. At the present time, this issue is not a continuing concern.
12. Status of agreement with LA County to provide faculty services at LAC+USC Medical Center. The contract for professional services with LA County still provides substantial income to the medical school and a large portion of salaries paid to clinical faculty. Uncertainty regarding the stability of this funding thus contributes to the tension over university guarantees for faculty compensation. Since l977, the medical school had provided physician services as a result of a County Professional Services Agreement (CPSA), negotiated at five-year intervals. For the past two years the contract has been extended while terms have been renegotiated. As some issues are resolved, new ones arise. Recent unionization of county employed physicians, which affects only about 50 at LAC, and the county’s obligation under Proposition A to demonstrate that the contract with the medical school is more cost effective than providing services directly now complicate the process. Also at issue is $6 million in research activities reflected in the Physician Time Allocation Modules and the difference in fringe benefit rates between the county at 21.75% and the university at 32%. Some of these issues were outlined in a June 30, l999 letter to the medical school faculty and is included in the appendix.
While negotiations continue faculty contracts now stipulate that the portion of faculty salary derived from the CPSA contract is not guaranteed. Administration officials remain confidant that a satisfactory arrangement with the County will result, and that in any event this will not affect the overall fiscal status of the medical school. Given the historical and financial significance of the school’s affiliation and the contribution to the educational and clinical programs the status of the contract negotiations will need to be closely monitored.
13. Improvements in space for educational program. Several improvements in space have occurred since the last full survey. Two lecture halls have been remodeled to incorporate additional seating as well as to be in compliance with ADA codes. Multiple left-handed chairs were also added. An overflow lecture room has been created to accommodate the additional students in the first year. This room is equipped with two-way audio and video, so that students can fully participate in the lecture if they so choose. As a consequence of the development of this facility and the need for professional video recording, all lectures are videotaped and available for student and faculty for review. Although this benefit will definitely be available for the class entering in 1999, it is uncertain whether it will continue for entering students in future years.
The multidisciplinary laboratories have also been refurnished in an effort to create more space for the class entering in 1999. Additional modular seating provides each student a desk and lockable storage area. The extra units are easily included in the laboratories without any compromise of space. Each of these rooms is equipped with computers so that students can access the extensive web-based educational materials that are part of the curriculum.
Formal small group teaching space is limited to the multidisciplinary laboratories that adequately serve this purpose. However, some small group instruction in the Introduction to Clinical Medicine Course must be held in a variety of casual, non-classroom settings, around the campus. Physical examination skills are taught in the laboratories and rooms used for standardized patient examinations. Although space for problem-based and case-based learning activities has always been limited, this year additional temporary space had to be identified to manage the larger first-year class. Students must be shuttled to this new space that is located off the central campus area. Small group space for problem-based and case-based learning remains a need.
14. Status of plans to build a replacement facility for the LAC+USC Hospital. After many years of effort, plans for construction of a replacement facility for the LAC+USC Hospital are moving forward with expected completion by 2005. The LA County Board of Supervisors has approved construction of a 600 bed hospital at a cost of $818 million, to be financed with $464 million in FEMA funds and $175 million from Medicare. The remainder will be provided through debt financing at an annual debt service of $20 million. Substantial plans have been developed and were shared with the survey team. The Board of Supervisors has also approved construction of a 60-150-bed facility in the East Los Angeles/San Gabriel Valley area, though financing and staffing have yet to be defined. Since medical school faculty already provide extensive clinical services at three comprehensive neighborhood health centers as part of the CPSA, it is not anticipated that the decrease in the size and redistribution of the inpatient service will affect the clinical programs. However, continued monitoring will be required.