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The Commonwealth Medical College: A New Model for a New Millennium

Northeastern Pennsylvania, like many non-urban areas in the United States, struggles with physician shortages which ultimately affect health care quality and access, as well as the local economy. A 2006 study found approximately 1/3 of local physicians are likely to retire in the next 10-15 years and the area will need more than 1,000 additional active physicians by 20251. In addition, nearly $1 billion in healthcare leaves the area annually.

In 2002, the Northeastern Pennsylvania community formed a consortium of representatives from business, government, medicine and the community to examine the feasibility of opening a new medical school. The result is The Commonwealth Medical College (TCMC), which will accept its first class of 60 students in the Fall of 2009.

TCMC is one of a number of new allopathic medical schools scheduled to open within the next ten years. These schools represent the first major expansion of medical schools since the 1960s and 1970s, which also saw the birth of the community-based medical school. TCMC is an example of the modern community-based medical school, whose founding was driven by a community movement and whose development is based upon the evidence gained in the past 40 years to build a truly community focused medical school.

While the founding of TCMC is not unique – the school was developed based upon the community's perceived need for more local physicians and a community movement which brought funding support from the State and Blue Cross of Northeastern Pennsylvania ($35 million and $25 million, respectively) – the choices of its founding architects have been unique.

From the outset, it was decided the school would not be part of a greater University in order to maintain flexibility around decision-making and achieving its mission to serve the community. Despite its status as a private institution, the medical school plans to accept 70% of its students from Pennsylvania, with the ultimate goal of accepting a majority from Northeastern Pennsylvania. Admission procedures involve community participants and strongly take into account each applicants interest in staying within the area and commitment to service. Prior to opening, the school is already setting the foundations for a minority, rural and lower socioeconomic status pipeline program, developing a partnership with Wilkes University and Luzerne County Community College.

Curriculum development has also followed the school's mission to produce physicians for the community:

• The curriculum follows a distributive model, with teaching to occur at 3 regional sites. Students will spend 3-4 weeks in one of these regional sites in each of the first and second years, and in the third and fourth years the students will be primarily assigned to a regional site.
• Students will follow a single family, often in their own homes, for the full four years of medical school.
• While TCMC has no stated primary care focus, students in their third years will spend up to 80% of their clinical time in ambulatory settings.
• Partnerships have been developed with other health professions schools to provide interprofessional education.

The goal of all of these strategies is to integrate the students into the community and prepare them for practice in these communities.

Prior to opening, however, TCMC is already facing barriers well known within medical education. Annual tuition is currently set at $35,000 for in-state students and $40,000 for out-of-state students. Dr. Robert D'Alessandri, the school's founding dean, reports his ultimate goal is to become a tuition-free medical school. Through philanthropic donations, every student in the charter class will be receiving an $80,000 scholarship ($20,000 per year), but stable funding for even these partial scholarships has yet to be established.

An additional barrier the community faces in retaining trainees in the area is the limited local graduate medical education (GME) positions. Currently, the area has nine GME programs (4 family medicine, 2 internal medicine, 1 general surgery, 1 osteopathic surgery, and 1 sports medicine) servicing 16 counties and approximately 1.5 million people. Recognizing physicians are most likely to stay in the areas of their GME training, the medical school and the community are working to expand GME programs. However, expansion has been significantly limited by regulations around Medicare GME and caps in resident positions set in the late 1990s.

TCMC's programs and barriers are not unique individually. However, TCMC is unique in its thoughtful application and integration of a number of programs proven to produce graduates interested in primary care and rural medicine. This will be a school to watch over the next decade as a model for existing and developing schools and likely for future innovations to address the barriers to community-based training and community retention.

Click here to visit the TCMC website.
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References

1. TrippUmbach. A Roadmap for Medical Renewal and Economic Development in Northeaster Pennsylvania. July 2006. Accessed April 7, 2009. Available at: http://www.scrantonchamber.com/pdfforms/MedSchool_ExecutiveSummary.pdf

The Sophie Davis School of Biomedical Education at the City College of New York

The Sophie Davis School of Biomedical Education at The City College of New York (CCNY) is a unique 7-year combined BS-MD program with a social mission. The program has been around for 35 years, and during those years has brought more than 1600 physicians into the workforce, many of them from under-represented minorities and many of them practicing primary care in underserved communities. Remarkably, many medical educators don't know of Sophie Davis; indeed, we think of ourselves as the least-known and most-focused medical school in the country. During this period when renewed attention is being paid to training more doctors who will meet the needs of our communities and address health disparities – not just more doctors who will participate in the grave imbalances of access and care that contribute to poor health outcomes from a population perspective – it might be a good time to examine the Sophie Davis model

During Sophie Davis students' 5 years on the City College campus, they participate in a curriculum which combines the requirements for a baccalaureate with the basic science components which usually reside in the first two years of a traditional medical school curriculum. Our students then transfer to one of 6 cooperating medical schools for their last two clinical years of education. Thus, their Bachelor's degree is from CCNY and their MD is from the cooperating school. The program was started in 1973 to improve diversity in the medical profession by providing a medical education for young people from groups that are under-represented. It has endured because that gap has persisted and because of the documented failure of doctors to practice medicine in geographic areas (rural and urban underserved) and specialty areas (primary care) that represent the greatest areas of need. This social imperative is codified in the form of a Service Agreement. Graduates of Sophie Davis pledge to serve the community after they complete residency, by working for a minimum of two years as a primary care physician in an underserved community.

High School students who come to Sophie Davis are a special group. They must be certain that they're going to be doctors and must also be committed to a primary care career. They have to be academically strong enough to thrive in an accelerated and compressed curriculum. They have to be intellectually nimble. One of the challenges that we've identified is that some of the young people who are needed the most in the ranks of the medical profession – those from low-income families which are African-American and Latino – are often those who attend high schools with limited resources, challenges and expectations. We have therefore developed strong and comprehensive support services.

Although our educational model resembles well-tested European and British models – we admit young people out of high school, and combine university and medical education – our program stands out as being "different" in the United States. As compared to the other BS/MD programs in the US, there is no sharp line at Sophie Davis between the "pre-clinical" sciences and the "basic" sciences. Similarly, the development of professionalism, clinical skills, and critical-thinking skills are continuous achievements, rather than being demarcated between college and medical school. There is a distinct and strong focus on community health and social medicine. Our graduates are younger than their class cohort when they begin their clinical clerkships at the six cooperating schools, which leads to a variety of challenges.

Most importantly, Sophie Davis is a school strongly driven by its mission, and we measure our success by mission-defined outcomes. We admit approximately 55% under-represented minorities, and about 45% of our graduates are URM. Until recently 40% of our graduates have chosen primary care specialties (i.e. primary care internal medicine, primary care pediatrics, family practice, and general obstetrics/gynecology). Approximately 40% of our graduates fulfill the Service Agreement; the other 60% are liable to pay an obligation of $75,000. We consistently strive to find ways to better fulfill our Mission.

The Sophie Davis model is important both functionally and historically. We demonstrate that it is possible to build a medical education around our vision of "Access, Excellence, Community." We consistently try to recruit young people with passion and potential from schools all over New York. We meet challenges head-on. Because we do not have our own clinical campus, however, we are dependent on the good will of our Cooperating Schools. These relationships have shifted over the years but have been remarkably stable and enduring at many schools.

We are grateful to the Medical Education Futures Study for the opportunity to bring the perspectives and experience of the Sophie Davis School to the discussion.

The Sophie Davis School of Biomedical Education
The City College of New York
Visit the Sophie Davis website

The Sophie Davis School Career Outcomes Study

Addressing the Urban Pipeline Challenge for the Physician Workforce: The Sophie Davis Model
Academic Medicine, December 2004

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Medical Education Futures Study

George Washington University School of Public Health and Health Services

Josiah Macy Jr. Foundation

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