The Social Mission of Medical Education: Ranking the SchoolsFREE
Publication: Annals of Internal Medicine
Volume 152, Number 12
Submit a Comment
Contributors must reveal any conflict of interest. Comments are moderated. Please see our information for authorsregarding comments on an Annals publication.
Abstract
This article has been corrected. The original version (PDF) is appended to this article as a supplement.
Background:
The basic purpose of medical schools is to educate physicians to care for the national population. Fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce.
Objective:
To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions.
Design:
Secondary analysis of data from the American Medical Association (AMA) Physician Masterfile and of data on race and ethnicity in medical schools from the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine.
Setting:
U.S. medical schools.
Participants:
60 043 physicians in active practice who graduated from medical school between 1999 and 2001.
Measurements:
The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score.
Results:
The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and non–community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas.
Limitations:
The AMA Physician Masterfile has limitations, including specialty self-designation by physicians, inconsistencies in reporting work addresses, and delays in information updates. The public good provided by medical schools may include contributions not reflected in the social mission score. The study was not designed to evaluate quality of care provided by medical school graduates.
Conclusion:
Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation. These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities.
Primary Funding Source:
Josiah Macy, Jr. Foundation.
Medical schools in the United States serve many functions, but one of their most basic purposes is to educate physicians to care for the national population. During the latter half of the 20th century, with federal and state support, medical education expanded to meet population needs (1). However, 3 specific interrelated issues challenged medical educators and policymakers: an insufficient number of primary care physicians, geographic maldistribution of physicians, and the lack of a representative number of racial and ethnic minorities in medical schools and in practice.
As early as the 1950s, commissions concerned with the medical workforce in the United States issued reports that raised these concerns (2–4). These reports helped launch legislation beginning with the Health Professions Educational Assistance Act of 1963 that provided support for expansion of medical education with particular attention to primary care, physician distribution, and educational opportunities for minority medical students. The National Health Service Corps, created in 1970, provided scholarships for students who committed to practice in underserved communities. Of the 28 allopathic medical schools opened with the aid of substantial state and federal support between 1970 and 1982, the Association of American Medical Colleges designated 17 as community-based (Salsberg E. Personal communication).
Nevertheless, problems in these 3 areas remain. Evidence increasingly shows that primary care is associated with improved quality of care and decreased medical costs (5, 6). However, an insufficient number of primary care physicians has hampered efforts to provide expanded health care access in states, such as in Massachusetts (7), and business groups and insurers have begun to speak out about the need for increased access to primary care (8).
Rural communities have a chronic shortage of physicians (9, 10), and federally supported community health centers report major deficits in physician recruitment (11, 12). African-American, Hispanic, and Native-American physicians continue to be severely underrepresented in the U.S. workforce. Underrepresented minorities made up 28% of the general population in 2006 (13) but accounted for only 15% of medical students and 8% of physicians in practice (14). These minority physicians provide a disproportionate share of health care to the growing minority U.S. population (15).
Medical schools contribute numerous important public goods to society beyond training the future physician workforce. They generate new scientific knowledge, are the home of leading-edge clinical treatments, and often provide substantial health care to underserved communities through their university hospitals and affiliates. Medical schools, however, are the only institutions in our society that can produce physicians; yet assessments of medical schools, such as the well-known U.S. News & World Report ranking system, often value research funding, school reputation, and student selectivity factors (16) over the actual educational output of each school, particularly regarding the number of graduates who enter primary care, practice in underserved areas, and are underrepresented minorities.
As citizens and policymakers reconsider the U.S. health care system and seek “quality, affordable health care for every American” (17), the nature of the physician workforce is becoming a key concern (18, 19). Many people believe that medical schools are accountable to society for their actions and accomplishments (20–22). Beyond their general educational mission, medical schools are expected to have a social mission to train physicians to care for the population as a whole, taking into account such issues as primary care, underserved areas, and workforce diversity (23–26).
We describe the analytic method that we used to measure the output of U.S. allopathic and osteopathic medical schools in these historically linked and traditionally challenging dimensions. We constructed a social mission score to summarize overall school performance in these areas.
Methods
Our analysis is based on the percentage of medical school graduates who practice primary care, work in health professional shortage areas (HPSAs), and are underrepresented minorities. The analysis was performed using data on graduates from 1999 to 2001 to capture the most recent cohort of graduates who had completed all types of residency training and national service obligations, such as the National Health Service Corps and the military's Health Professions Scholarship Program, both of which may involve up to 4 years of service. These factors were essential to determine graduates' actual choices of location and specialty rather than intermediary placements.
We analyzed multiple years to account for annual variations and included the 141 U.S. allopathic and osteopathic schools that graduated students between 1999 and 2001. We used the 2008 American Medical Association (AMA) Physician Masterfile to calculate the percentage of graduates practicing primary care and located in HPSAs. All physicians except for those listed as residents or fellows or those employed as administrators, primarily engaged in research or teaching, or who were no longer active (7.4% of the study group) were included. International medical school graduates were excluded. We used publicly available data on the race and ethnicity of graduates from the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine (27) to calculate the percentage of graduates who were underrepresented minorities.
We obtained standardized values for each of the 3 measures, with a mean value of 0 (SD, 1).
Primary Care Measure
Primary specialty information from the AMA Physician Masterfile was used to calculate the percentage of primary care graduates for each medical school. Primary care physicians included those in family medicine, general internal medicine, general pediatrics, or internal medicine pediatrics.
HPSA Measure
The Health Resources and Services Administration identifies HPSAs on the basis of 3 primary criteria (population–provider ratios, poverty rate, and travel distance or time to the nearest accessible source of care) and several secondary criteria (including infant mortality and low-birthweight rates and proportion of the population younger than 18 years or older than 65 years. We calculated the percentage of graduates from each medical school with an address in an HPSA. Health professional shortage area geographic data were downloaded from the Health Resources and Services Administration's Geospatial Data Warehouse (28). We geocoded addresses from the AMA Physician Masterfile by using the spatial mapping tool ArcGIS (ESRI, Redlands, California) to determine physician location within a primary care HPSA using geographic and population-based definitions of primary care HPSAs to determine the greatest number of graduates working in HPSAs.
This method probably overestimates the number of physicians practicing in underserved areas by including some physicians working in non-HPSA settings, such as academic health centers. For physicians with a preferred mailing address not identified as a work address, we used the alternative address, if available, to increase the likelihood of obtaining a work rather than home address (29).
Underrepresented Minority Measure
On the basis of conventions used by the Association of American Medical Colleges, we defined underrepresented minorities as African-American, Hispanic, and Native- American persons. For the medical school graduating classes of 1999 to 2001, we divided the total number of underrepresented minority graduates for each medical school by the total number of graduates to create a raw percentage of minority medical school graduates for each school. Because the percentage of underrepresented minorities among states varied substantially, we adjusted each school's raw percentage.
Public medical schools primarily admit students from within their states; therefore, we calculated the ratio of the proportion of underrepresented minorities graduated by the school to the proportion of underrepresented minorities living in the state. For private schools, which admit students from a more national pool, we calculated the ratio of the proportion graduated by the school to the national proportion. We calculated ratios for public and private Puerto Rican schools by using the proportion of underrepresented minorities in Puerto Rico because these schools primarily recruit from and produce physicians who practice in Puerto Rico. To calculate the percentage of state and national underrepresented minorities, we used data from the U.S. Census Bureau.
Three historically black medical schools with a high proportion of graduates who are underrepresented minorities created a significantly skewed distribution. To normalize the skewed distribution, we calculated the standardized scores without these 3 schools, then reincluded them by using the calculated mean value and SD.
Composite Index and Aggregate Analysis
We constructed a composite score by using a simple sum of these 3 standardized measures. We also developed an alternative composite score comprising the sum of each school's within-component ranking on a theoretical scale from 3 (1 + 1 + 1) to 434 (141 + 141 + 141) (rank-sum approach). We reported results using the composite measure sum ranking because these findings were not very different from those using the rank-sum approach and because the simple sum measure preserves information about the magnitude of differences across schools for each measure.
We also analyzed schools in aggregate by geographic region, size of the metropolitan area of the school's main campus, private or public status, National Institutes of Health (NIH) support (30), allopathic or osteopathic status, and classification as a community-based school by the Association of American Medical Colleges and determined weighted mean scores for each classification (Appendix). Because of the differences in school sizes, the numbers of graduates per school were weighted into the mean value. We obtained regional classifications from the U.S. Census Bureau (31) and county size classifications from the U.S. Department of Agriculture's Rural–Urban Continuum Codes (32). We used analysis-of-variance models to compare the composite scores and the 3 specific scores across different school characteristics.
Role of the Funding Source
This study was conducted as part of the Medical Education Futures Study, which is funded by the Josiah Macy, Jr. Foundation to examine the social mission of medical education during the current period of medical school expansion. The funding source had no role in the study design, data collection, or interpretation of results.
Results
Table 1 shows the 20 schools with the highest and lowest social mission scores and the primary care, HPSA, and underrepresented minority measures on which the schools' composite scores were based. The ranking of all 141 schools is in the Appendix.
Aggregate analyses (Table 2) suggest differences in social mission score and components by geographic region and the size of the metropolitan area in which the schools are located. No region was clearly advantaged in all 3 measures; however, the South, West, and Midwest had positive social mission scores, whereas the Northeast had a negative social mission score. Western schools produced more primary care physicians, and Southern schools produced more physicians who practice in underserved areas. Southern schools also had the largest percentage of underrepresented minorities among their graduates but, after correction for underrepresented minorities in the regional population, had the same relative representation of minorities as Midwestern schools. Schools in progressively smaller metropolitan areas produced increasingly more primary care physicians and physicians who practice in underserved areas but graduated fewer underrepresented minorities.
Compared with allopathic schools, osteopathic schools produced relatively more primary care physicians but trained fewer underrepresented minorities. Public schools scored higher on the composite social mission score and in all 3 component measures, although the differences between public and private schools were not statistically significant for the underserved area and underrepresented minority components.
Funding by the NIH was inversely associated with social mission score and with a school's output of primary care physicians and physicians practicing in underserved areas. Community-based schools scored higher than non–community-based schools in the composite social mission score and in all 3 component measures, although the differences between community-based and non–community-based schools were not statistically significant for the underserved area and underrepresented minority components.
School rankings obtained by using the social mission score in a secondary analysis based on the rank-sum approach were strongly correlated with rankings obtained by using the social mission score as a sum of composite score measures (r = 0.971). Fifteen of the top-20 schools in the composite-score sum rankings were also ranked among the top-20 schools when the alternative rank-sum scoring method was used. Giving greater weight to individual outliers with our composite measure caused some of these differences. For example, the University of Mississippi ranked 13th on social mission on the basis of composite score measures but 63rd in the alternative rank-sum ranking, because a very high percentage (62.5%) of the school's graduates practice in HPSAs; the school's relatively low percentage of graduates who practice primary care (33.5%) or are underrepresented minorities (school–state ratio, 0.23) contributed to its lower score compared with the sum of each school's within-component ranks.
Discussion
Primary care physician output, practice in underserved areas, and a diverse physician workforce have persistently challenged the U.S. health care system and medical education. This analysis reveals substantial variation in the success of U.S. medical schools in addressing these issues.
Ranking schools is not new. Since 1983, U.S. News & World Report has published rankings of colleges and graduate schools (33) that are based on the amount of sponsored research at the schools; student selectivity criteria, such as Medical College Admission Test scores and grade point averages; and subjective assessments made by medical school deans and residency directors (34). In 1995, U.S. News & World Report added a primary care rating system that takes into account the percentage of graduates entering primary care residencies. However, their primary care rating continues to include faculty opinion and student-selectivity measures (17). Moreover, this system does not measure the actual number of graduates entering primary care practice after completing their residencies or score the number of graduates who practice in underserved areas or are underrepresented minorities. Because of these differences, our results vary considerably from the U.S. News & World Report's rankings. Our findings suggest numerous areas that are relevant to public policymakers and medical educators as they consider the design of new medical schools and the expansion of current ones.
The 3 historically black colleges and universities with medical schools (Morehouse School of Medicine, Meharry Medical College, and Howard University) score at the top of the social mission rankings. These results are not unexpected, as 70% to 85% of each of these schools' graduating classes were underrepresented minorities compared with only 13.5% in all medical schools during the same period. The higher underrepresented minority scores alone significantly increase these schools' social mission scores. However, all of these schools also score in the top half of the primary care and underserved output measures.
Previous studies have shown that underrepresented minority physicians provide relatively more care to minority and underserved populations compared with nonminority physicians (35, 36). Our findings, in conjunction with these studies, suggest that expansion programs focused on the recruitment and training of underrepresented minority medical students could have disproportionately favorable effects on the geographic misdistribution of physicians and inadequate primary care workforce.
Public schools graduate higher proportions of primary care physicians. Public schools also seem to graduate greater proportions of physicians practicing in underserved areas and of minority physicians than private schools; however, the differences between public and private schools in these 2 components were not statistically significant. These findings indicate that public schools are more responsive to the population-based and distributional physician workforce needs that concern legislators, and suggest that enhanced support for medical education at the state level could address workforce needs more effectively than would investment in private schools.
Furthermore, the higher social mission score of community-based medical schools suggest that a school's explicit commitment to educate physicians who will pursue careers compatible with community needs has long-term effects on the career choices of its graduates. However, the difference between the high proportion of graduates practicing in underserved areas and that of minority physicians at these schools was not statistically significant compared with those of non–community-based colleges, and the successes of Morehouse School of Medicine (1 of the 17 community-based colleges and a clear outlier in at least the underrepresented minority component) may have contributed to the higher social mission score for community-based colleges overall.
The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas. High levels of research funding clearly indicate an institutional commitment to research and probably indicate missions that value technical medicine and specialization rather than training in primary care and practice in underserved areas. Our findings suggest that schools with smaller research portfolios are more likely to focus on training physicians for community and population needs, although schools in the lowest quartile of NIH funding also scored lower for underrepresented minority output than did schools with higher levels of NIH funding. Nevertheless, we propose that educational ranking systems that place significant weight on research funding may confuse discussions of national educational policy by conflating research values with national clinical needs.
Compared with other U.S. regions, the Northeast, with its preponderance of private, traditional, and research-intensive medical schools, had the lowest scores in the primary care and underserved areas components and a distinctly lower social mission score. The size of the metropolitan area in which schools are located also seems to affect the social mission score. For example, medical schools in less urban areas were more likely to produce primary care physicians and physicians practicing in underserved areas. These findings may be particularly useful for individuals or organizations considering building new schools or developing branch campuses of existing schools.
Our findings indicate that osteopathic schools continue to place substantially more graduates into primary care and marginally more graduates into underserved areas, suggesting that osteopathic medicine has continued to be influenced by its traditional focus on primary care and rural practice (37–39). However, allopathic schools have recruited more underrepresented minorities than osteopathic schools. Osteopathic medicine has been creative in establishing new schools in nontraditional locations, such as Pikeville, Kentucky, and Harlem, New York, and in developing innovative community-based programs, such as A.T. Still University in Mesa, Arizona, where all clinical work is based at 1 of 10 community health centers. The outcomes of these programs need to be measured, but their flexibility and inventiveness commend them to planners concerned with training a broad-based physician workforce.
Our analysis also provides an opportunity to identify schools that defy the trends. Four large research institutions (University of Minnesota; University of Washington; University of California, San Diego; and University of Colorado) are in the top quartile of medical school recipients of NIH funding and of primary care output rankings. In addition, University of Washington and University of Minnesota are in the top quartile for overall social mission score. These findings invite questions about what factors influence graduates of these schools to choose primary care and whether those influences might be transferable to other schools. Our findings also raise questions about why some community-based public medical schools that seem well situated to have high social mission scores do not have them.
Our study has limitations. First, we used the AMA Physician Masterfile as a primary data source, although self-designation by physicians, inconsistencies in reporting work addresses, and a delay in information updates (40–42) raise concerns about its accuracy. Where possible, we addressed these problems by, for example, attempting to minimize location inaccuracy by preferentially using secondary addresses when the primary address was a home address. These shortcomings may cause some inaccuracies, but we did not clearly identify any likely systematic biases.
Second, we selected a 1999 to 2001 graduating class cohort to allow graduates to complete transitional placements in residency training and service obligations. Our findings therefore do not reflect changes in medical school policies in the past 10 years and social mission performance of newer medical schools. These factors suggest the need for future analyses, possibly on an ongoing basis, to monitor more recent performance or trends.
Third, our measurement of social mission may raise objections on the grounds that the values taught in medical school are subject to influences beyond the control of medical educators, such as specialty incomes, student debt, and lifestyle preferences. Although this concern is understandable, medical schools as an enterprise have enormous influence over the creation of physicians, including the location and mission of the school and its recruitment and admission practices, curriculum, and values that the faculty model for students. No other institution involved in creating physicians has as much influence as the medical school. The variable career patterns of graduates of different medical schools, as shown here, seems to validate the premise that schools have considerable influence in the type of graduate that they produce.
Finally, our measure of social mission says nothing about the quality of education that medical schools provide or the quality of care that their students deliver 7 to 9 years after graduating. Standardization of competency is ensured in the U.S. medical education system through institutional and individual accreditation processes, such as the Liaison Committee on Medical Education and the United States Medical Licensing Examination, respectively, as well as through specialty certification processes by medical specialty boards meant to verify and maintain the quality of graduates. In this context, we propose that graduates of schools with strong social mission measures are likely to be among the most well-prepared practitioners for primary care and for the care of minority or underserved populations.
In conclusion, we found substantial variation in the success of individual U.S. medical schools in recruiting and educating students to address the social mission of medical education, defined as graduating physicians who practice primary care and work in underserved areas and recruiting and graduating young physicians who are underrepresented minorities. Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation. A diverse, equitably distributed physician workforce with a strong primary care base is essential to achieve quality health care that is accessible and affordable, regardless of the nature of any future health care reform.
Supplemental Material
References
1.
Schofield JR. New and Expanded Medical Schools: Mid-Century to the 1980s. San Francisco: Jossey-Bass; 1984.
2.
President's Commission of the Health Needs of the Nation. Building America's Health: Findings and Recommendations. Washington, DC: US Gov Pr Office; 1952.
3.
Coggeshall LT. Planning for Medical Progress Through Education. Evanston, IL: Assoc of American Medical Coll; 1965.
4.
The Carnegie Foundation for the Advancement of Teaching. Higher Education and the Nation's Health: Policies for Medical and Dental Expansion. New York: McGraw-Hill; 1970.
5.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273-87. [PMID: 12585825]
6.
Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502. [PMID: 16202000]
7.
Sack K. In Massachusetts, universal coverage strains care. New York Times. 5 April 2008. Accessed at www.nytimes.com/2008/04/05/us/05doctors.html on 10 May 2010.
8.
Patient-Centered Primary Care Collaborative. Accessed at www.pcpcc.net on 5 May 2010.
9.
Council on Graduate Medical Education. Physician Distribution and Health Care Challenges in Rural and Inner-City Areas. Tenth Report. Rockville, MD: U.S. Department of Health and Human Services; 1998.
10.
Ricketts TC, Randolph R. The diffusion of physicians. Health Aff (Millwood). 2008;27:1409-15. [PMID: 18780931]
11.
Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. JAMA. 2006;295:1042-9. [PMID: 16507805]
12.
National Association of Community Health Centers. Access Transformed: Building a Primary Care Workforce for the 21st Century. Bethesda, MD: National Assoc of Community Health Centers; 2008.
13.
U.S. Census Bureau. Annual estimates of the resident population by sex, race, and hispanic origin for the United States: April 1, 2000 to July 1, 2008. 2008. Accessed at www.census.gov/popest/national/asrh/NC-EST2008-srh.html on 5 May 2010.
14.
American Medical Association. Total physicians by race/ethnicity—2006. Accessed at www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/minority-affairs-consortium/physician-statistics/total-physicians-raceethnicity-2006.shtml on 5 May 2010.
15.
Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood). 2000;19:76-83. [PMID: 10916962]
16.
Morse R, Flanigan S. The medical school methodology. U.S. News & World Report. 15 April 2009. Accessed at www.usnews.com/articles/education/best-medical-schools/2009/04/22/medical-school-rankings-methodology.html on 5 May 2010.
17.
Obama BH. Speech to the Joint Sessions of Congress [transcript]. CNN. 24 February 2009. Accessed at www.cnn.com/2009/POLITICS/02/24/sotn.obama.transcript/ on 5 May 2010.
18.
U.S. Senate Committee on Finance. Workforce Issues in Health Care Reform: Assessing the Present and Preparing for the Future. Committee Hearing. 12 March 2009. Accessed at finance.senate.gov/hearings/hearing/?id=d82650ed-02b3-b69f-ad34-5d6c8843a5de on 5 May 2010.
19.
U.S. House of Representatives Committee on Energy and Commerce. Making Health Care Work for American Families: Improving Access to Care. Hearing—Subcommittee on Health. 24 March 2009. Accessed at energycommerce.house.gov/index.php?option=com_content&task=view&id=1546&Itemid=95 on 5 May 2010.
20.
Mitka M. Report: Growth of medical schools brings opportunity to redefine their mission. JAMA. 2009;301:1114-5. [PMID: 19293406]
21.
Boelen C, Heck JE. Defining and Measuring the Social Accountability of Medical Schools. Geneva: World Health Organization; 1995.
22.
Schroeder SA, Zones JS, Showstack JA. Academic medicine as a public trust. JAMA. 1989;262:803-12. [PMID: 2664241]
23.
White KL, Connelly JE. The medical school's mission and the population's health. Ann Intern Med. 1991;115:968-72. [PMID: 1683197]
24.
Woollard RF. Caring for a common future: medical schools' social accountability. Med Educ. 2006;40:301-13. [PMID: 16573665]
25.
Kaufman A, Galbraith P, Alfero C, Urbina C, Derksen D, Wiese W, et al. Fostering the health of communities: a unifying mission for the University of New Mexico Health Sciences Center. Acad Med. 1996;71:432-40. [PMID: 9114858]
26.
Freeman J, Ferrer RL, Greiner KA. Viewpoint: Developing a physician workforce for America's disadvantaged. Acad Med. 2007;82:133-8. [PMID: 17264689]
27.
Association of American Medical Colleges. Minority Students in Medical Education. Washington, DC: Assoc of American Medical Coll; 2002.
28.
U.S. Department of Health and Human Services Health Resources and Services Administration Geospatial Data Warehouse. Accessed at datawarehouse.hrsa.gov/ on 5 May 2010.
29.
Ricketts T. Impact Testing of the Proposed Revised Methodology for Designating Underserved Areas [draft of a final report]. U.S. Department of Health and Human Services Health Resources and Services Administration. 10 August 2007.
30.
National Institutes of Health Research Portfolio Online Reporting Tools. Accessed at report.nih.gov/index.aspx on 5 May 2010.
31.
U.S. Census Bureau. Census regions and divisions of the United States. Accessed at www.census.gov/geo/www/us_regdiv.pdf on 5 May 2010.
32.
U.S. Department of Agriculture Economic Research Service. Measuring rurality: rural–urban continuum codes. Accessed at www.ers.usda.gov/briefing/rurality/ruralurbcon/ on 5 May 2010.
33.
McGaghie WC, Thompson JA. America's best medical schools: a critique of the U.S. News & World Report rankings. Acad Med. 2001;76:985-92. [PMID: 11597837]
34.
Sehgal AR. The role of reputation in U.S. News & World Report's rankings of the top 50 American hospitals. Ann Intern Med. 2010;152:521-5. [PMID: 20404383]
35.
Council on Graduate Medical Education. Minorities in Medicine: An Ethnic and Cultural Challenge for Physician Training. An Update. Seventeenth Report. Rockville, MD: U.S. Department of Health and Human Services; 2005.
36.
Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, et al. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med. 1996;334:1305-10. [PMID: 8609949]
37.
Simpson C, Simpson MA. Complexity of the healthcare crisis in rural America. J Am Osteopath Assoc. 1994;94:502-8. [PMID: 7880239]
38.
Tooke-Rawlins D. Rural osteopathic family physician supply: past and present. J Rural Health. 2000;16:299-300. [PMID: 11131779]
39.
American Osteopathic Association. Osteopathic medicine. Accessed at www.osteopathic.org/index.cfm?PageID=ost_omed on 5 May 2010.
40.
Freed GL, Nahra TA, Wheeler JR; Research Advisory Committee of American Board of Pediatrics. Counting physicians: inconsistencies in a commonly used source for workforce analysis. Acad Med. 2006;81:847-52. [PMID: 16936499]
41.
Grumbach K, Becker SH, Osborn EH, Bindman AB. The challenge of defining and counting generalist physicians: an analysis of Physician Masterfile data. Am J Public Health. 1995;85:1402-7. [PMID: 7573625]
42.
Konrad TR, Slifkin RT, Stevens C, Miller J. Using the American Medical Association physician masterfile to measure physician supply in small towns. J Rural Health. 2000;16:162-7. [PMID: 10981368]
Comments
Sign In to Submit A CommentInformation & Authors
Information
Published In
Annals of Internal Medicine
Volume 152 • Number 12 • 15 June 2010
Pages: 804 - 811
History
Published online: 15 June 2010
Published in issue: 15 June 2010
Keywords
Authors
Metrics & Citations
Metrics
Citations
If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.
For more information or tips please see 'Downloading to a citation manager' in the Help menu.
Download article citation data for:
The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med.2010;152:804-811. [Epub 15 June 2010]. doi:10.7326/0003-4819-152-12-201006150-00009
The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med.2010;152:804-811. [Epub 15 June 2010]. doi:10.7326/0003-4819-152-12-201006150-00009
View More
Login Options:
Purchase
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
Access to EPUBs and PDFs for FREE Annals content requires users to be registered and logged in. A subscription is not required. You can create a free account below or from the following link. You will be redirected to acponline.org to create an account that will provide access to Annals. If you are accessing the Free Annals content via your institution's access, registration is not required.
Create your Free Account
You will be redirected to acponline.org to create an account that will provide access to Annals.
A Clarification
Thanks for the interesting article. I look forward to seeing more research done in this area. I just wanted to point out that the name of our medical school is Morehouse School of Medicine, not Morehouse College as listed in Table 1 of the article.
Morehouse School of Medicine is a completely separate institution from Morehouse College, and I feel this should be clarified because many people believe that the school of medicine does not accept female or non- minority students, which is contrary to the fact.
Sincerely,
Sahil C. Tah, MD
Chief Resident of Internal Medicine
Morehouse School of Medicine
Conflict of Interest:
None declared
Research Medical Schools Serve Important Social Mission
Dear editor,
When I was eight years old, my father, newly diagnosed with alpha-1- antitrypsin deficiency (A1ATD), underwent his first liver transplant. His diagnosis and treatment underscore the importance of every day advances in medical discovery. In 1989, the DNA mutations underlying A1ATD had only recently been described, liver transplants were considered experimental surgery, and his survival hinged on successful immunosuppression--at the time bolstered by the recent introduction of cyclosporine. It has been over 22 years since we thought he was going to die. He is still alive thanks to the highest specialty care and medical research.
This provided my motivation to pursue MD/PhD training at the school ranked number 129 by the scoring system of Mullen, et al (1). The research performed during that time will, hopefully, soon be utilized towards better diagnosis and detection of disease. My reward is extended residency and fellowship training so I can fight to establish myself as a physician- scientist. For this extensive training, I can expect much lower pay, lower job security, less location flexibility, and increased work-hours compared to private practice. Still, I committed myself to becoming a physician- scientist because I believe in the social mission of medical research.
Through grants and donations, research medical schools graduate many future physician-scientists who will discover new ways to combat disease. This is only a part of the school's overall mission. We provide the highest level of specialty care for a large number of patients who cannot be served elsewhere in the area. In addition, vast amounts of general and uncompensated care are provided for the community.
I believe that I grew up very disadvantaged. I come from a lower middle class background with a mother with severe mental illness and my father with A1ATD and many complications. I lived in mostly African- American neighborhoods and I am a high school dropout. Yet the "social mission ranking" implies that my mission and my diverse background are unimportant and leaves my work uncounted.
That is a pity. Because many of the world's smartest, most driven physicians and physicians-in-training train and work among the longest in medicine for a social mission--the social mission of discovering new cures for disease. It is because of that mission that I had a father to grow up with.
Sincerely, Eric A. Mellon, PhD University of Pennsylvania, Combined Degree Program, MD/PhD Training Year 8
References
1. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. Ann Intern Med 2010 152:804-811
Conflict of Interest:
None declared
Fundamentally Wrongheaded
This is one of the most disturbing articles I have ever seen in the Annals.
First of all, the idea of ranking the nation's medical schools in any way is conceptually flawed. This is an endeavor that ought to be left to the tabloid press, rather than given the imprimatur of a scientific journal.
More importantly, I think that this article profoundly misconstrues the purpose of medical education.
To quote the abstract, "The basic purpose of medical schools is to educate physicians to care for the national population." That statement is somewhat softened in the text itself to read, "Medical schools in the United States serve many functions, but one of their most basic purposes is to educate physicians to care for the national population."
I submit that the "basic purpose" of medical schools is to educate physicians to care for their patients.
Caring for a patient is very different than caring for a population.
I suggest that interested readers refresh their memories of Philip Tumulty's article on the role of the clinician (NEJM 1970;283:20-4), Francis Peabody's article on the care of the patient (JAMA 1927,88;877- 882.)
In order to fulfill the purpose of enabling physicians (and surgeons, inter alia) to care for patients, medical schools have other subsidiary roles, such as the generation of new medical treatments, the elimination of scientific and medical error, and also the promotion of the public health. But those are not their basic and most fundamental purpose.
It is probably impossible for the faculty and staff any one school to fully develop its ability to achieve every purpose in medicine to the highest pitch, and therefore some schools will do better in some areas than other areas. It is therefore not useful to rank schools in the unidimensional way that the authors of this paper have done.
But let me return to their fundamental misconception of the "basic purpose" of a medical school. They betray a fundamental misconception of the nature of medicine and of the responsibilities of physicians and surgeons generally, because they elevate the abstract and derivative notion of the health of the population above the real, concrete work of caring for individual patients. They exalt and reify an idea above the work that doctors actually do.
Public health investigations and public health administration are laudable endeavors, but they are not the basic purpose of medical practice.
To a large degree, I suspect that the folk-marxist ethos in which from his other voluminous writings at least Fitzhugh Mullan appears to operate may account for the article's emphasis on population-based public health rather than the actual practice of medicine. That "groupism" however also generally infects medical science as a whole, since epidemiological evidence has now come to be considered the only sort of evidence to which physicians should attend. The problem is that epidemiologic evidence, including randomized clinical trials, produces results only regarding entire populations, and can not be translated to the care of individual patients without clinical experience and clinical wisdom.
The fact that the basic purpose of medicine is being forgotten is part of a process that is ending the era of what I will call Oslerian medicine. Some, like Franklin Paine Mall, might have been happy to see that era end much sooner than now. However, I think that the basic experiences of practicing medicine and of being a patient are changing in ways that benefit neither patients nor clinicians.
The practice of medicine is being dumbed down to the level of technical procedures carried out on a "population" by feldschers or "barefoot doctors" at the behest of a State-controlled bureaucracy. The system will work very well for those who wish to tabulate the percentage of patients whose physicians inquire about seat-belt use. It will not work so well for a worried, sick woman whose intermittent fevers and evansecent abdominal discomfort require the full and undivided attention of an experienced and thoughtful clinician.
Conflict of Interest:
None declared
Correction in Table 1
At position number 15 in the lowest 20 table, the "University at Albany, State University of New York" is listed. That institution has no medical school. Certainly the authors were referring to Albany Medical College, in Albany NY, where I completed my residency in Internal Medicine.
Albany Medical College is part of Union University. Union College, Union Graduate College, Albany Medical College, Albany Law School, Albany College of Pharmacy, and the Dudley Observatory of the City of Albany are united and known as Union University.
The listing of Albany Medical College is correct in the appendix of the article.
Conflict of Interest:
None declared
Problems with Social Mission Study
The study is troublesome for several reasons. 1] There are mechanical problems. Table one has two readily apparent errors, The University of Medicine and Dentistry of New Jersey is comprised of three distinctly different medical schools and there is no medical school at SUNY Albany, are there more errors? 2] The cohort used may have been necessary to determine practice choices but it was not necessary to determine diversity of entering classes. My own school made dramatic improvements over the next ten years in this regard and thus is falsely depicted on this score. 3] The underlying assumption is that educators' social responsibility, as perceived at any point in time, supercedes their responsibilty to tell their students the truth. As a medical school dean for almost 18 years I stopped lying to my students about the rewards of adult primary care when it became obvious that they were going to be few compared to specialty care. Perhaps academic physians need to take an oath to Socrates the teacher as well as to Hippocrates the physician.
Conflict of Interest:
None declared
No Title
Mullan et. al's piece on the social mission of medical education is a provocative one. In other areas of healthcare the creation of league tables, even when the underlying measurement is inaccurate, has led to greater attention to the subject being measured. This surely was the case with this article. Unfortunately the authors did get it very wrong in the case of the Uniformed Services University of the Health Sciences, which it characterized as being among the 20 lowest on their "Social Mission Score." That conclusion obviously ignores the reality of that unique school. Among its attributes is the fact that 100% of its graduates are committed to public service. More importantly the vast majority of their graduates find themselves spending at least part of their professional lives providing care in the most austere environments, ranging from battlefields to remote outposts and refugee camps. This amount of service to the most vulnerable would fit any rational definition of "social mission" yet has been completely been ignored by the authors. The social mission of USUHS is one for which our nation should be proud and to ignore it creates a false impression at best and at worst is frankly disrepectful to those who serve.
Conflict of Interest:
Dr. Meyer is a former Colonel in the U. S. Air Force Medical Corps and continues to serve as adjunct faculty at the Uniformed Services University of the Health Sciences
Teaching Hospital Provision of Care to Un and Under Insured - a Fourth Indicator of Social Mission?
Dear Editor:
In an era where professionalism in medicine is increasingly promoted, Mullan and colleagues have brought fresh data and perspective to support a more evidence-based dialogue on the mission of medical education. In addition to the outcome measures of primary care, practice in shortage areas and inclusion of underrepresented minorities we offer a 4th indicator for consideration - the proportion of un and under insured patients cared for in the medical school's teaching hospitals. Given the important socializing effects of medical education, teaching students and residents in institutions which make it a priority to serve all patients provides an early anchor point for a key component of professionalism - social justice.
Scott Barnhart, MD, MPH, FACP Professor, Departments of Medicine, Global Health and Environmental and Occupational Health Sciences (Adjunct) University of Washington
James LoGerfo, MD, MPH, FACP Professor, Departments of Medicine, Global Health and Health Services (Adjunct) University of Washington
Conflict of Interest:
None declared
Medical Education and the Social Mission of Medical Schools
Motivating medical students to enter primary care and work in health professional shortage areas requires healing the historical schism between schools of medicine and public health and focusing medical education more on the socioeconomic, cultural, psychological, occupational, and environmental contributors to illness. Health policy, social justice, human rights, environmental health, and reproductive rights are given short shrift(1,2). Despite calls for increased emphasis on global bioethics (3), aside from informed consent and end-of-life care contemporary ethics discourse and training overemphasizes fascinating dilemmas involving expensive technologies (gene therapy, cloning, prenatal genetic diagnosis and treatment, and face transplants), while inadequately addressing public health(1,2). Barriers to social sciences instruction include: lack of perceived relevance for clinical practice; limited curricular time; lack of qualified instructors; a dearth of commitment from deans and department chairs; inadequate funding; and a paucity of role models.
Furthermore, many academic institutions have recently limited clinic slots for un- and under-insured patients, while promoting luxury care clinics for the privileged (usually without cross-subsidizing indigent care), perpetuating a two-tiered system of care and sending the wrong message to trainees, who should be learning to treat all patients equally(4).
Modification of medical schools' affirmative action policies to focus on social class as well as race may improve care for the underserved, since physicians' socio-economic origins correlate with their patterns of service to the disadvantaged(5). Community service, mentored service- learning assignments, and activist-oriented research projects would provide students greater insight into their patients' health and social problems.
Physicians are obliged, because of their privileged status, the public's investment in their training, and their roles as stewards of the public's health, to be politically active and ensure that our leaders provide for the sickest among us. Unfortunately, physicians have lower adjusted voting rates than the general population. When doctors lobby Congress, they focus more on reimbursement and research funding than on access to care, tobacco control, women's rights, violence prevention, and other social justice issues(1).
Physicians also have a responsibility to oppose, individually and collectively, forces contributing to the spread of poverty, including over -consumption; mal-distribution of wealth; the economic, political, legal, and educational marginalization of women; environmental degradation; racism; human rights abuses; and militarization and war.(1,2) This is especially true now, when fewer scientists hold positions of authority than in times past, and when scientific truths are deliberately obfuscated by the well-funded and sophisticated public relations and lobbying campaigns of those with a vested interest in profiting from environmental degradation and the provision of a basic human right like health care.
References
1. Donohoe MT. Roles and responsibilities of health professionals in confronting the health consequences of environmental degradation and social injustice: education and activism. Monash Bioethics Review, 2008;27(Nos. 1 and 2):65-82. Available at http://phsj.org/wp- content/uploads/2009/01/monash-env-ethics-paper-with-pg-nos.pdf. Accessed 6/29/10.
2. Donohoe MT. Stories and Society: Using Literature to Teach Medical Students about Public Health and Social Justice. International J of the Creative Arts in Interdisciplinary Practice (IJCAIP) 2009 (Issue 8). Available at http://ijcaip.com/archives/IJCAIP-8-Donohoe.html. Accessed 6/29/10.
3. Dwyer J. Teaching global bioethics. Bioethics 2003;17(5-6):432-46.
4. Donohoe MT. Standard vs. luxury care, in Ideological Debates in Family Medicine, S Buetow and T Kenealy, Eds. (New York, Nova Science Publishers, Inc., 2007). Available at http://phsj.org/wp- content/uploads/2008/04/luxury-medical-care-ideological-debates-in-family- medicine.pdf. Accessed 6/29/10.
5. Magnus SA and Mick SS. Medical schools, affirmative action, and the neglected role of social class. American Journal of Public Health, vol. 90, no. 8, 2000, pp. 1197-1201.
Martin Donohoe, MD, FACP
Adjunct Associate Professor, School of Community Health
Portland State University
Chief Science Advisor, Campaign for Safe Foods and
Member, Board of Advisors
Oregon Physicians for Social Responsibility
Senior Physician, Internal Medicine, Kaiser Sunnyside Medical Center
http://www.publichealthandsocialjustice.org
http://www.phsj.org
[email protected]
Conflict of Interest:
None declared
The Physician-in-Training's Perspective on the Social Mission Score
We applaud Fitzhugh Mullan and colleagues for their innovative study (1) that provides a stark contrast to the dominant U.S. News and World Report rankings. As medical trainees, we hope that the medical community will not only embrace the concept of social mission but actively engage in the development of more robust metrics. This study represents great progress toward improving the quality of medical education in this country - and toward holding medical schools accountable for producing a cohort of physicians capable of addressing the multifaceted needs of our nation's health.
Using Mullan's study as a springboard, the social mission of medical education warrants further discussion. This study excludes any consideration of research - whether basic science, translational or health services - in calculating social mission score. While NIH research funding alone is a poor proxy for social mission, wholesale exclusion of research's contribution to social mission is similarly myopic. Medical school curriculum is also a critical element of social mission. Undergraduate medical education is not a benign process. What and how core medical concepts are presented and taught colors students' perspectives on what it means to be a physician. Even vital aspects of our curriculum in medicine, such as the development of our professional values, are gleaned by simple exposure to other physicians (2). Finally, from lobbying on Capitol Hill to assisting an individual patient in navigating the labyrinth of our health care system, the social mission of medical education ought to incorporate a measure of the advocacy role physicians must embrace in our fragmented health system. A survey of U.S. physicians lends credence to this need to provide training to physicians- in-training, as 90 percent of practicing physicians felt that advocacy was important, yet only one-third of these physicians actually engaged in any activities around advocacy (3).
Recent suggestions of clearer definitions of terms (4), the use of modeling, and the need for further financial support for advocacy should be integrated into Mullan's discussion of a social mission in medicine. As physicians-in-training, we wholeheartedly support better defining the social mission of medicine and its ramifications on our education and look forward to the next iteration of social mission rankings.
References
1. Mullan, F. Chen, C. Petterson, S. Kolsky, G. Spagnola, M. (2010). The social mission of medical education: ranking the schools. Annals of Internal Medicine 152(12):818-819.
2. Baernstein, A. Oelschlager, A.M. Chang, T.A. Wenrich, M.D. (2009). Learning professionalism: perspective of preclinical medical students. Academic Medicine 84(5): 574-581.
3. Gruen, R.L. Campbell, E.C. Blumenthal, D. (2006). Public roles of U.S. physicians. JAMA 296(20):2467-2475.
4. Earnest, M.A. Wong, S.L. Federico, S.G. (2010). Physician Advocacy: What Is It and How Do We Do It? Academic Medicine 85(1):63-67.
Conflict of Interest:
None declared
Dear Editor
I entered medical school with a resolve to plunge into social justice, join Medecins sans Frontieres upon graduating and travel the globe in an effort to eradicate HIV and AIDS. But something unexpected happened during these last four years. I found that I enjoyed studying many areas of medicine. I began to see that my envisioned career was often at odds with every other objective a young person might be expected to have: family, home, stability. I found that my service oriented projects, already strung out by my limited time and flexibility, were largely swallowed whole by the demands of wards and patient care during my third year. If it were just me I might chalk these events up to incompetence, but unfortunately the struggle to incorporate service and humanism practically is one that likely many medical students can relate to.
Many of my friends and colleagues have wrestled with these difficult choices at length in private and in silence, during early morning drives on empty roads, in the depths of night at deserted hospital cafeterias and cafes, individual battlegrounds being contested on behalf of social welfare without recognition or recourse. Medical culture does not leave much room to waiver, and even less to do so publicly, and it can be easy to be overwhelmed by the competing demands of ethics, profession, society and family. We turn to friends, family and faculty for support and encouragement but eventually face the realization that the choices we make cannot be shared, and that the path we choose is ours and ours alone. In that moment some bend under the pressure, realism superseding idealism.
It is likely true that elite medical schools should be and frequently are searching for new avenues to promote and encourage underserved paths for their graduates. The mechanics of these agendas I do not know. What I do know is that in spite of the hurdles, generations of medical students have labored to balance their professional and private lives, personal time against precious minutes with patients. And that ultimately within the artificial decisions of what specialty to pursue, of where to live and practice lies the more meaningful pursuit of true dedication to and passion for our work, courage to stand for what we believe in and to do right, and conviction that the choices borne out of these principles will be vindicated.
Conflict of Interest:
None declared
Commitment and Complexity of the Social Mission of Academic Health Centers
Vanderbilt University School of Medicine (VUSM) considers social responsibility to be a central component of its mission as a university medical center, both locally and nationally. This priority is reflected in broad features of activity, ranging from our research agenda to our clinical and educational enterprises.
One of our commitments during the past decade has been to broadly diversify our medical school class. This effort has provided a new richness to Vanderbilt's medical education programs while greatly expanding the number of minority physicians and physician scientists coming from our school.
Our incoming class is one of the most diverse in the US, with 23 percent of the 105 students from groups underrepresented in medicine (URM). Similarly, 15 percent of the entering class of 111 Ph.D. students are URMs who will one day seek careers in biomedical research.
The efforts are not only producing minority physicians to provide healthcare, but also future medicine and biomedical research leadership who will focus on the pressing questions aimed at the urgent priorities of all members of American society.
One of the important aspects of our research goals is service to our nation. We are engaged in the Southern Community Cohort Study, one of the largest longitudinal epidemiological projects addressing racial and ethnic health disparities, along with partners including Meharry Medical College. Together, over 70,000 individuals, mostly African-American, have been recruited to help us understand the causes of high cancer mortality in African Americans.
Locally, VUSM is committed in numerous ways to the health of our community including those underserved individuals. The Shade Tree student- run health clinic, initiated by our medical students seven years ago, provides needed healthcare for free to our surrounding community. The medical center also provides nearly half of all uncompensated care in Davidson County, with $325 million projected for fiscal year 2010.
The commitment of a university medical center to social responsibility, while important, requires consideration of the broad array of factors that reflect the tremendous complexity of each academic health center's mission and its unique roles locally and nationally.
As Jeff Balser, our Dean and Vice Chancellor for Health Affairs, recently noted, "like our peer institutions, we are compelled, and challenged, to align our strategies and resources in a manner that nourishes our local community, while at the same time addressing the compelling national and international problems in health care. Both priorities are fundamental to fulfilling social responsibility -- a responsibility that Vanderbilt proudly embraces through commitment, innovation and leadership."
George C. Hill, PhD Associate Dean for Diversity in Medical Education Bonnie M. Miller, MD Senior Associate Dean for Health Sciences Education John A. Zic, MD Associate Dean of Admissions Vanderbilt University School of Medicine Nashville TN 37232
Conflict of Interest:
None declared
Discussion of Social Mission of Medical Education Article
We have been gratified by the interest that "The Social Mission of Medical Education: Ranking the Schools"has generated. We recognize the many benefits that medical schools provide, including basic and clinical research as pointed out by Dr. Mellon and clinical services to uninsured patients as pointed out by Dr. Barnhart. Medical schools, however, receive considerable approbation for these activities - including accolades and funding. The social mission, as we've defined it, garners far less recognition or support. We have frankly been surprised by the reactions of some respondents that examining the record of the nation's medical schools in regard to the practice locations, specialty choices and ethnicity of their graduates is somehow unfair or devalues their school or their career choices.
We acknowledge concerns raised about the lack of inclusion of curriculums of public health and ethics (Dr. Donohoe) and professional values and advocacy (Dr. Brockman). These are extremely important in developing attitudes and skill sets that contribute to an environment where the social mission of education is valued. Dr. Meyer's admonition that the Uniformed Services University of the Health Sciences score was not reflective of the school's service to the nation is well taken. The measures used and the point of measurement of this study did not capture the career dedication to the military mission of the graduates of USUHS.
While one can appreciate Dr. Edelman's many contributory years as a medical educator, one would hope that his grim view of primary care would not become the policy of his faculty, particularly in light of the struggle between idealism and realism experienced by many young people in medicine as described by Dr. Deng. We also note that several hundred thousand American physicians work in primary care and in shortage areas today and while they are not as numerous as needed, most of these physicians have satisfying careers and live financially comfortable lives.
We also recognize that the challenge (personal and institutional) of the social mission of medical education is not limited to the medical school years and that change needs to occur concurrently in all aspects of medical education from admissions through graduate medical education and in practice organization and reimbursement. The Patient Protection and Affordable Care Act takes initial steps to address some of these issues and our study brings focus to the role of medical schools within this overarching effort to construct a system that provides equitable health care for the nation.
Finally, this study is only a single step in examining the social mission of medical education. As many have pointed out, there are additional factors that need to be examined and correlated with social mission outcomes and updates need to be done to evaluate ongoing medical school efforts to address the social mission of medical education.
Fitzhugh Mullan, MD Candice Chen, MD, MPH
Conflict of Interest:
None declared