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From humble beginnings, Iowa emerges as a national
leader in graduate medical education
At 4 p.m. in late April 1919, a distinguished-looking
gentleman stepped off a train in Iowa City and was greeted
by then-University of Iowa President George MacLean.
MacLean didn't realize it then, but by the time the
visitor left on the midnight train that evening, Iowa's
medical education program would be forever changed.
The visitor was Abraham Flexner, the most influential
medical education reformer of his day. During his short
stay, Flexner found grievous fault with Iowa's medical
school and teaching hospital and issued a damning report.
Similar devastating reports led to the demise of over
half the 155 American and Canadian medical schools reviewed
by Flexner, so there was plenty of reason for concern.
However, much to Flexner's surprise, his report energized
Iowa's commitment to medical education rather than signaled
its downfall. Instead of closing the medical school and
teaching hospital, the State Legislature supported the
building of a new medical campus. Ironically, Flexner
himself played a key role in helping secure matching funds
for the project through the Rockefeller Foundation.
Still, no one-least of all Flexner-could have envisioned
the leadership role that University of Iowa Health Care
would eventually play in the field of graduate medical
education (see related sidebar for details of current
appointments).
R. Edward Howell's role as chair-elect of the American
Council on Graduate Medical Education executive committee is
particularly high profile, and comes at a time when graduate
medical education nationwide is facing unprecedented stress
and strain.
A former public school educator, Howell held various
administrative responsibilities and academic appointments at
the Medical College of Georgia and the University of
Minnesota before coming to Iowa as director and CEO of UI
Hospitals and Clinics.
He is a currently a clinical professor in the UI College
of Public Health, where he teaches in the Program of Health
Services Management.
As executive committee chair-elect, Howell recently urged
the Council to promote greater awareness of the importance
of graduate medical education in America. He and other
members of the University of Iowa Health Care leadership
team are particularly concerned about finding ways to
nurture and develop expert full-time clinical faculty
("clinician-educators").
Clinician-educators have become increasingly important as
academic medical centers struggle to meet the challenges of
today's competitive health care marketplace. This stressful
environment has forced most academic medical centers to
expand their clinical services while continuing their
commitments to research and education.
Al Burgener, associate director at UI Hospitals and
Clinics, said, "as competition has intensified, many faculty
physicians have found it necessary to concentrate even more
time on research or patient care, thereby placing greater
pressure on the faculty time available for teaching. These
growing pressures make it essential that we challenge our
traditional assumptions about how we teach resident
physicians in clinical settings."
Burgener added, "there has been relatively little change
in the way in which resident physicians are taught in major
teaching hospitals over the past few decades, even as the
way in which patient care is provided has changed markedly".
According to Howell, therein lies the value of
clinician-educators. Clinical-track faculty members devote
the vast majority of their time to patient care and to
teaching medical students and resident physicians. General
medicine, family medicine, and internal medicine
practitioners treat large numbers of patients (often 20 to
25 per day) in their clinics on a daily basis.
"In its simplest form, graduate medical education is
learning by doing," Howell said. "It is the transfer of
knowledge gained in the classroom and laboratory into
practice. For this to occur, however, highly skilled
clinicians who are dedicated to training and who have a
reasonable level of financial security are absolutely
essential."
Howell is concerned that the system of support for
clinical faculty is inadequate, leading to frustration and
dissatisfaction. Last year, over one-third of the graduate
medical education program directors were new to their role,
a level of instability that challenges the very framework of
graduate medical education, Howell said.
"This makes it difficult to maintain morale and retain
top-quality clinicians and teachers, and threatens academic
medical centers' traditional missions of education, patient
care, and research," he said. "That's why it is important
that we find new ways to develop and support our
clinician-educators. They are very important to our future."
In support of that effort, The University of Iowa
recently decided to allow individual colleges to vote on
whether to increase the number of clinical-track faculty
members. This decision is expected to lead to an increase in
the number of clinical-track faculty employed by University
of Iowa Health Care, the partnership between the UI
Hospitals and Clinics and UI College of Medicine.
In many ways, the leadership roles played by Howell,
Burgener, College of Medicine Dean Robert Kelch, MD, and
others associated with University of Iowa Health Care
personify the institution's emergence as a national leader
in graduate medical education.
Abraham Flexner, the great health care reformer, would no
doubt be pleased.
At the forefront
University of Iowa Health Care administrators and faculty
hold key appointments in several areas of graduate medical
education. They include:
R. Edward Howell, director and CEO of UI Hospitals
and Clinics, chair-elect of the executive committee of the
American Council on Graduate Medical Education. The Council
is responsible for accrediting post-MD medical training
programs within the United States, using a peer review
process.
Alan J. Burgener, associate director of UI
Hospitals and Clinics, chair of the Association of American
Medical Colleges (AAMC) Group on Resident Affairs. AAMC is a
nonprofit association of 125 accredited U.S. medical
schools, 16 accredited Canadian medical schools, and more
than 400 major teaching hospitals and health systems. The
Group on Resident Affairs is an AAMC subgroup that focuses
on financing, organization, and administration of residency
training programs. Burgener also serves on an AAMC task
force formed to develop new ways of integrating patient care
and graduate medical education within academic medical
centers challenged by today's competitive health care
marketplace. In addition, he recently was appointed to the
AAMC Task Force on Institutional Accountability for Graduate
Medical Education. Burgener previously chaired an AAMC work
group on GME program sizing.
Robert Kelch, MD, dean of the UI College of
Medicine, liaison from the AAMC's Council of Deans to the
AAMC's Group on Resident Affairs. Kelch also is a member of
the administrative board of the AAMC Council of Deans.
Continuing a long tradition of University of Iowa
leadership in residency issues at the national level, two
current faculty members chair Residency Review Committees
appointed by the American Council on Graduate Medical
Education. These committees establish standards for
residency training in all the medical specialties:
- Gail McGuinness, MD, Pediatrics;
- John Van Gilder, MD, Neurosurgery;
Even the staff of the Accreditation Council for Graduate
Medical Education has Iowa ties through Ingrid
Philibert, ACGME's Director of Field Staff. Philibert
previously served on the administrative staff of UI
Hospitals and Clinics and currently is enrolled in UI's
doctoral program in Hospital and Health Administration.
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