Class Size Recommendation
Principles of Medicine Committee statement and recommendation to the Medical Curriculum Committee on UVa Medical School Class Size
September 19, 2007
In the draft report of the Commission on the Future of the University's Committee on Schools and the Medical Center, the School Plan Summary from the School of Medicine states: "When the [Claude Moore Medical Education Building] opens, class size will increase by approximately 20 students (15%) from 142 to162 per year."
The Principles of Medicine Committee recommends (by a vote of 25-1) that the UVa School of Medicine NOT increase the medical student class size beyond the current level of 142 students per year. The voting was done by e-mail and these 26 votes represent course directors from ALL courses in both the Foundations of Medicine (10 courses) and Core Systems (6 courses) portions of the medical curriculum, as well as 4 medical student representatives to the committee. Reasons for this recommendation are discussed below.
We would like to note the report prepared by Carolyn Engelhard (health policy analyst in the Department of Public Health) in April 2000 entitled: "Quantity, Quality and Medical education: would less mean more if we reduced UME class size at UVa". This report considers the arguments for reducing medical class size. Among the individuals interviewed for the report (12 faculty members directly involved in medical education administration at UVa, 1 retired alumnus and 1 former student, Dr. Engelhard indicated that "support for reducing class size was universal" (p.5).
The UVa School of Medicine has severe limitations on the ability to provide clinical training on site to our current medical student class, given the small town setting and limitations on patient number and diversity, as well as size of the clinical faculty. This has long required that we utilize remote Clerkship training sites requiring that students spend a significant proportion of their Clerkship period away from Charlottesville. This has created problems in ensuring a comparable experience at multiple sites, a problem we are still grappling with and one for which we were cited in the recent LCME reaccreditation report. (noncompliance Item 1 in Feb 28, 2007, letter from the LCME to President Casteen).
Recent events within the state have lessened the need for UVa to produce increased numbers of physicians while at the same time putting at risk some of our "away" training sites:
At the same time, the above developments at other state schools are putting at risk our ability to adequately train the medical students that we currently enroll. With the Carilion Roanoke hospital involved in starting up its own medical school, UVa may lose access to a significant number of Clerkship training slots we have depended on in Roanoke. With MCV expanding its class, this may create problems with a Northern Virginia training site (Fairfax, already on the MCV schedule rather than the UVa schedule) currently utilized by UVa. If this is a point in time when we are simultaneously looking for new training sites in other locations in the state (Augusta, Rockingham) while trying to address the LCME concern about our ability to deliver comparable educational experiences at all sites, this is the worst possible time to be considering an expansion of class size. Any increase in medical class size would most likely increase the percentage of time that each UVa medical student spends away from Charlottesville. Additional site concerns, with an expanded size class, include our ability to find suitable ambulatory medicine training sites as a part of the AIM Clerkship and our ability to find and supervise enough service-learning sites for the Social Issues in Medicine (SIM) course.
An increase in class size would also create difficulties for the early years of the curriculum, particularly in terms of small group teaching. We are attempting to increase the amount of small group teaching that is done in the medical curriculum. PoM1 and PoM2 require a large number of faculty in order to staff the small groups. Indeed, the Curriculum Committee has wrestled with the problems of how to find sufficient physicians to staff the small groups in the PoM2 course. New courses (such as Cells to Society and Basic Science for Careers) have been or are being instituted that require staffing of additional small groups. Increasing the class size would require additional small group instructors for all of these courses, as well as additional small group rooms. Even with the recent addition of a number of small group teaching rooms in the Health Sciences Library, we are facing a real problem with small group teaching spaces at a time that we are about to implement the new Basic Science for Careers course. Virtually no small group teaching spaces have been designed into the new Claude Moore Medical Education Building. An increase in class size will create serious problems for laboratory small group teaching in the first two years of the curriculum. The Jordan Hall 2nd floor medical school teaching labs (that are used for Cell and Tissue Structure/Physiology, Physiology/Cell and Tissue Structure, Pathology, Microbiology and Life-Saving Techniques courses) has a maximum capacity of 147 medical students. Even if an expanded class could fit into the existing laboratory teaching space, there would be a requirement for additional lab groups and lab instructors. In a similar manner, the proposed medical class expansion would require a minimum of four more dissection tables in the Gross Anatomy labs, which would be a problem in an already crowded space. There would also need to be an increase in staffing in the Gross Anatomy labs. Note that the new Claude Moore Medical Education Building does not include any facilities for laboratory teaching.
The need for additional small group and laboratory instructors comes at a time when disincentives for the faculty to invest more of their time in medical education are rising. Clinical faculty members are under pressure to maximize clinical and/or research income. Basic science faculty members are coming under increased pressure to maintain grant income and salary reimbursement at a time when NIH grant funding is becoming more competitive and more time must be invested in the quest for research grant dollars and the research data that justifies them. Indeed, this draft report on the Future of the University acknowledges this when it states: "Over the past several years, economic pressures have led to fewer faculty who are willing to teach." (p. 8 of the School of Medicine School Plan of the Commission on the Future of the University).
If we are to maintain the quality of the educational experience for the physicians we train, the quality and selectivity of our entering medical school classes and increase the national ranking of the school of medicine, we think that the School of Medicine is well advised to emphasize quality over quantity in medical education and to maximize faculty-student ratio and patient-student ratio, especially in an atmosphere laden with challenges (pressures on away training sites, LCME concerns, pressure on clinical faculty to maximize clinical income, pressure on basic science faculty to maximize research grant income).
Robert A. Bloodgood, Chair
for the Principles of Medicine Committee