Jefferson Med Study

Jefferson Med Study - The Iefferson—Penn State B S —-M...

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Unformatted text preview: The Iefferson—Penn State B. S. —-M. D. Program. A 26~year Experience CLARA CALLAHAN, M. D. I. ION VELOSKI, M. S. GANG XU, PhD. MOHAMMADREZA HOIAT, Ph. D., CARTER ZELEZNIK, Ph. D., and Abstract—Since the 19605 a number of physicians have com- pleted both their baccalaureate and their M.D. degrees in six or fewer years. In this longitudinal study the authors track the academic performances, clinical ratings, and career follow-up data of 659 students in one of these accelerated programs, the Jefferson Medical College—Pennsylvania State University BS.— M.D. program, from entering years 1964 through 1989. The med- ical school performances, clinical performances in residencies, IOSEPH S. GONNELLA, MD. and rates of board certification and faculty appointment of the The traditional undergraduate educa- tion of physicians in the United States has been based on four years of baccalaureate education followed by four years in a medical college. Dur- ing the late 19508 and early 19603 many medical colleges considered, and some implemented, accelerated baccalaureate-MD. programs in which students recruited directly from high school were able to com- plete the requirements for both de- grees in only five or six calendar years.“3 The major factors that .en- couraged the development of 'these programs included a shortage of phy- sicians; a desire to eliminate the over- lap between the baccalaureate and medical curricula; an attempt to re- duce the cost 'of a medical education for both students and colleges; and a desire to attract the academically tal- Dr. Callahan is associate clinical professor of pediatrics-and associate dean for student af- fairs; Mr. Veloski is director of medical educa- tion research, Center for Research in Medical Education and Health Care (CRMEHC); Dr. Xu is research associate, CRMEHC; Dr. Hojat is director of the longitudinal study, CRMEHC; Dr. Zeleznik is senior research as- sociate, CRMEHC; and Dr. Gonnella is profes- sor of medicine, director of CRMEHC, and se- nior vice president for academic affairs and dean; all are at Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania. Correspondence and requests for reprints should be addressed to Dr. Callahan, Jefferson Medical College, 1025 Walnut Street, 100 Col- lege, Philadelphia, PA 19107-5583. For related papers, see pages 783 and 785. 792 ented student who might have been lost to medicine because of the length of time involved to earn a medical degree. Pennsylvania State University (Penn State) and Jefferson Medical College (JMC) in 1963 initiated an accelerated program in which highly qualified students could receive both the BS. and the MD. degrees in five calendar years after graduation from high school.‘ At the program’s incep- tion, applicants had to be in the top 20% ‘of their high school classes and have combined verbal and quantita- tive scores on the Scholastic Aptitude Test (SAT) over 1,200. Students began the baccalaureate program at Penn State immediately after gradu- ating from high school and entered the medical curriculum at Jefferson one year and three months later. In 1984 a change in the academic calen- dar at Penn State extended the pro- gram to six years. Because of the academic accelera- tion undertaken by the students in the baccalaureate component of this program, a need for continuing evalu- ation of the program was recognized from its onset. Special attention was directed to the collection of data on students in the accelerated program as part of a comprehensive longitu- dinal study of all graduates of JMC. The present study was designed to ex- amine the premedical, medical, and postgraduate performances of stu- dents in the accelerated program compared with those of students in the usual eight-year curriculum, over accelerated students compared favorably with those of a control group of medical students with similar high school credentials who had followed a four-year baccalaureate program. The au- thors conclude that a carefully chosen group of students can achieve high academic standards in an accelerated medical school program, graduate as younger physicians able to perform well in postgraduate training, and go on to highly productiVe careers in medicine. Acad. Med. 67(1992): 792— 797. -, a 26-year period. - The accelerated students were compared with two groups of nonac- celerated students: a group with aca- demic records that would not have qualified them for the accelerated program and a more comparable group of highly qualified students who had the academic records re- quired by the program. Using this de- sign, we hypothesized that the accel- erated students would be more similar to, and at least as successful as, the highly qualified students, and that both groups would be different from the other students. Method The 4,448 matriculants who entered JMC between 1964 and 1989 Were di- vided into three groups. The acceler- ated group consisted of the 659 matri- culants in the accelerated program. The control group was made up of the 814 matriculants who could have qualified for the accelerated program based on their total scores on the SAT, but who followed the conven- tional baccalaureate program. The other group consisted of the other 2,975 matriculants, who could not have qualified for the accelerated program. Variables The independent variable for our study was group of students (acceler- ated, control, or other). The sets of dependent variables were those for ACADEMIC MEDICINE premedical performance (undergradu- ate grade point averages — GPAs — in science and in nonscience courses), performance during medical school, and performance after graduation. Performance during medical school included freshman GPA, which was calculated using grades in major freshman courses (anatomy, bio- chemistry, mechanisms of disease, and physiology); sophomore GPA, based on grades from sophomore courses (microbiology, pathology, and pharmacology); junior grades (written examinations and clinical evaluations in the six core clerkships: family med- icine, internal medicine, pediatrics, obstetrics—gynecology, psychiatry, and surgery); total scores on the Na- tional Board of Medical Examiners (NBME) Part I and Part II examina- tions; attrition from medical school; and delayed graduation (requiring more than four years to complete the MD. degree). We also looked at stu- dents’ educational debts and choices of specialty in both freshman. and se- nior years of medical school. We used actual amounts of debt as recorded in the Office 'of Student Financial Aid, rather than self-reported data. Performance after graduation in- cluded scores on NBME Part III and ratings of clinical competence in the first year of residency. For NBME Part III, the data Were available for 71% of the total graduates who had entered JMC from 1964 through 1985; these gave permission for the medical school toobtain their scores. Similarly, data on clinical compe- tence were available for 74% of the graduates who had matriculated at JMC through 1985. A rating form de- signed to measure four aspects of clinical competence in the areas of medical knowledge, data-gathering skills, clinical judgment, and pro- fessional attitudes .was sent each year to the director of medical educa- tion at hospitals that accepted JMC graduates in their residencies.“ The form contained 33 specific statements covering these four areas. Each state- ment described objectively an ob- servable characteristic related to professional behavior and asked the observer to make a judgment on a four-point Likert-type scale regarding Volume 67 0 Number ll 0 NOVEMBER I992 the extent to which the graduate had shown that behavior in actual prac- tice. A rating of 4 indicated that the resident belonged to the highest quar- tile of all residents known to the rater, whereas 1 indicated the lowest quartile. The other performance variables after graduation were specialty, board certification, and type of employ- ment. Reports of actual specialty were available for all graduates (through the entering class of 1983) by means of the surveys conducted through the American Board of - Medical Specialties (ABMS) and the American Medical Association (AMA). Statistical Analysis The data were electronically retrieved from the database of JMC’s longitu- dinal study of students and alumni. For the variables with interval scales, an analysis of variance (ANOVA) was performed with group as the indepen- dent variable. Following the signifi- cant main effect, a Tukey post hoc test was performed. For nominal data, chi-square tests were conducted. Z- tests were performed for specific pro- portion comparisons. The signifi- cance level for all tests was set at p < .05. Results The results are reported in three main sections, one for each set of de- pendent variables. Premedical For undergraduate GPAs (science and non-science), we found signifi- cant main effects of group. Tukey post hoc tests revealed that the accel- erated group of students had higher mean science and nonscience GPAs than did the control and other groups, but there was no significant differ- ence between the latter two groups. During Medical School . Means of the variables related to the students’ performances in medical school and on the NBME Part I and Part II examinations are presented in Table 1. For freshman GPA, sopho- more GPA, junior written examina- tions, and NBME Part II scores, a consistent pattern was manifested in each of four significant main effects of group. The students in the other group had statistically significantly lower scores than did the students" 1n the accelerated program and in the control group, whereas there was no difference between the latter two groups. However, on NBME Part I, the control group had a statistically significantly higher score than did the accelerated group, which had scores higher than the other group. In addi- tion, on core clerkship clinical evalua- tions, there was no significant difi'er- ence among the three groups. Delayed graduation and attrition. Forty-four (6.7%) of the students in the accelerated program required more than four years to complete the M. D. program compared with 28 (3. 4%) of the students' 1n the control group and 140 (4. 7%) in the other group. The Z-test bf proportion indi- cated that the number of students in the accelerated program who gradu- ated late compared with the number in the control or other group was sta- tistically significant. Out 'of the total number of 44 accelerated‘students who had delayed graduation, only nine (20%) had academic difficulties (defined as failure of one of the courses during medical school or fail- ure in one of the NBME examina- tions). In comparison, 13 (46%) of the 28 in the control group. and 88 (63%) of the 140 in the other group gradu- ated late because of academic dif- ficulty. Twenty~one (48%) of the accelerated students had delayed graduation for nonacademic reasons. The remaining 14 (32%) had both ac- ademic and nonacademic reasons for the delays in their graduation. Seventeen students (2.6%) of the accelerated group, 22 (2.6%) of the control group, and 65 (2.2%) of the other group dropped out or did not graduate from'medical school. An examination of the records indicates that eight (47%) of these accelerated students, 12 (54.5%) of these control students, and 47 (72.3%) of these other students left school because of 793 Table 1 Performance Data for Students in the B.S.—M.D. Accelerated Program and Two Groups of Traditional Students, Jefferson Medical College, Entering Years 1964— 1989* Junior Freshman Sophomore Written NBME NBME GPA GPA Examinations Part I Part II Group Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Accelerated (n = 659) 83.2 (5.4) 82.3 (5.6) 83.5 (4.3) 534 (92) 558 (93) Control (n = 814) 83.6 (5.3) 82.6 (5.0) 83.4 (4.1) 552 (83) 560 (89) Other (71 = 2,975) 82.6 (5.3) 81.4 (5.1) 82.3 (4.2) 514 (83) 512 (92) F1' 10.08 ' 15.82 22.53 63.69 71.93 p .001 .001 .001 .001 .001 *For a longitudinal study of the performances of the students in the Jefferson Medical College-Pennsylvania State University B.S.—M.D. program, the authors used various performance measures and follow-up career data to compare the 659 students in this accelerated program with two groups of traditional students: a control group of 814 highly qualified students, who had the academic records required by the program, and the other 2,975 students, who did not have the qualifications. The numbers of students in each group varied for each performance measure; the data for the written examinations and Part II of the National Board of Medical Examiners (NBME) examination were not available for the students entering in 1988 and 1989. 'I'F-tests were performed with group as the independent variable. academic difficulties. The differences among groups were not statistically significant. Educational debt. The actual « amounts of each student’s debt at the time of entering medical school (freshman debt) and at graduation from medical school (senior debt) were adjusted to constant dollars in the base year of 1991 by means of the Consumer Price Index. (Senior debt included both premedical and medical school debt but excluded spouse’s debt.) To estimate the freshman and senior debt levels for the groups, we determined the total numbers of stu- dents having some educational debt at the beginning of medical school and at graduation. Statistical analysis was performed on the mean debt at entry and at graduation. Statistical analysis was performed on the mean Table 2 Freshman and Senior Debt Levels and Percentages of Students in Debt for Students in the B.S.—M.D. Accelerated Program and Two Groups of Tradi- tional Students, Jefferson Medical College, Entering Years 1964— 1989* Freshman Mean % with Senior? Mean % with Group Debt ($) Debt Debt ($) Debt Accelerated 4,619 23 25,903 69 Control 7,895 28 29,020 62 Other 8,315 28 30,985 68 Average 7,846 27 29,984 67 F1: 13.23 6.78 p .001 .001 ‘For a longitudinal study of the performances of the students in the Jefferson Medical College— Pennsylvania State University B.S.—M.D. program, the authors used various performance mea- sures and follow-up career data to compare the 659 students in this accelerated program with two groups of traditional students: a control group of 814 highly qualified students, who had the academic records required by the program, and the other 2,975 students, who did not have the qualifications. The calculations of the means were based on the students who bad debts, and the values were adjusted to constant dollars in the base year of 1991 by means of the Consumer Price Index. The data for freshman debt were available for the entering classes of 1973 through 1989, and the data for senior debt were available for the entering classes of 1967 and of 1973 through 1986. Tlncludes both premedical and medical school debt but excludes spouses’ debt. iF-tests were performed with group as the independent variable. 794 debt of only students with indebted- ness (27% of freshmen and 67% of seniors). For freshman debt, the main effect of group was significant, show- ing that students in the accelerated program had less debt in their fresh- man year than did those in the con- trol or other group, whereas there was no significant difference between the latter two groups (Table 2). The dif- ference between the means of senior debt for the accelerated and other group was statistically significant, but the difference between the means for the accelerated and control groups was not statistically significant. Specialty plans. The students were asked as freshmen and later‘ as se- niors about their plans for specializa- tion after their first year of postgrad- uate training. Data were available for 76% of freshmen and 86% of senior students. (Data for senior choice of specialty were available only through the entering class of 1986.) Students’ choices of specialty were classified as follows: primary care (family medi- cine, internal medicine, or pediatrics), internal medicine subspecialties, ob- stetrics—gynecology, psychiatry, sur- gery, and others. Z-tests of proportion found that freshman students in the accelerated program were less likely to choose a primary care specialty (27%) compared with freshmen in the control group (40%) or the other ACADEMIC MEDICINE Table 3 Mean Scores on Residents’ Competence and NBME Part III for Graduates of the B.S.—M.D. Accelerated Program and Two Groups of Traditional Graduates, Jefferson Medical College, 1968— 1989* Competency Ratings during Residency Clinical Data-gathering Clinical Professional NBME Knowledge Skills Judgment Attitudes Part III Group Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Accelerated 3.10 (.71) 3.16 (.63) 3.09 (.64) 3.20 (.63) 551 (93) Control 3.16 (.62) 3.19 (.57) 3.16 (.61) 3.25 (.60) 545 (96) Other 3.01 (.71) 3.13 (.60) 3.11 (.62) 3.27 (.60) 515 (94) Fl‘ 4.73 1.03 0.73 2.24 14.52 p .01 .35 .48 .11 .01 *For a longitudinal study of the performances of the students in the Jefferson Medical College—Pennsylvania State University B.S.—M.D. program, the authors used various performance measures and follow-up career data, for entering years 1964-1989, to compare the 659 students in this accelerated program with two groups of traditional students: a control group of 814 highly qualified students, who had the academic records required by the program, and the other 2,975 students, who did not have the qualifications. This table presents data for the following percentages of all the 1964-1985 graduates: 71%, for NBME III scores, and 74%, for ratings of clinical competence. Competence was rated according to a four-point Likert-type scale, where a rating of 4 indicated the resident was in the highest quartile of all residents known to the rater, and 1 indicated the lowest quartile. 1'F-tests were performed with group as the independent variable. group (39%). However, these statisti- cally significant differences disap- peared in the seniors’ choices of pri- mary care (44%, 45%, and 46% for accelerated, control, and other, re- spectively). None of the other propor- tion comparisons was statistically significant. After Graduation In general, in each of the four areas of clinical competence rated by hospi- tals’ directors of medical education— medical knowledge, data-gathering skills, clinical judgment, and profes- sional attitudes—no significant dif— ference was found among the three groups. However, in the area of clini- cal knowledge, the control group per- formed significantly better than did the other. There was no statistically significant difference between the ratings of the accelerated group and those of either of the other two groups (Table 3). As with Part II of the NBME examinations, students in the other group had a significantly lower mean score on Part III than did stu- dents in the accelerated program and in the control group, but there was no difference between the latter two groups. Data on actual specialty were avail- able from the ABMS and the AMA Volume 67 0 Number 11 I NOVEMBER I992 for 3,351 (99.7%) of the living gradu- ates through the entering class of 1983. Z-tests of proportion indicated that there were more students from the control group (32%) and from the other group (34%) than from the ac- celerated group (27%) in the actual practice of primary care. For most of the other variables used in assessing graduates after medical school, complete data were available through the entering class of 1982. A 3 X 5 contingency table of group by type of practice (direct pa- tient care, administrative, teaching, research, and postgraduate fellow- ship) was significant ()52 = 26.13, p < .01). Z-tests of proportion showed that more physicians who had been in the control (90%) or in the other group (89%) were more in- volved in direct patient care than were those who had been in the accel- erated program (82%). We also con- structed a table of board certification (yes versus no) by ...
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