JMWatt Consulting Firm's Report to TOMA on the Proposed MD school at UNTHSC

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JMWatt Consulting

Report to the Texas Osteopathic Medical Association

Development of an Allopathic Medical School at the University of North Texas Health Science Center

February 7, 2011

David F. Altman, MD, MBA

J. Michael Watt, MBA

JMWatt Consulting ● Altman


REPORT TO THE TEXAS OSTEOPATHIC MEDICAL ASSOCIATION ON DEVELOPMENT OF AN ALLOPATHIC

MEDICAL SCHOOL AT THE UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER

Executive Summary

At the request of the Texas Osteopathic Medical Association (TOMA), we have reviewed The “Academic and Business Plan for the Development of a Proposed MD Program” (“the Plan”) that the Regents of the University of North Texas (UNT) approved in October 2010 to develop a new school of allopathic medicine (UNTMD) in Fort Worth. This Plan was said to be in response to a growing perception that there is a looming crisis in the availability of physicians, particularly in primary care. In addition, and perhaps paradoxically in view of the primary care crisis, it is based on the idea that there would be advantages, both for residency training programs now being developed by local hospitals and for clinical practice in general, for there to be an expansion of allopathically trained graduates instead of a further increase in the number of osteopathic-trained graduates through the Texas College of Osteopathic Medicine (TCOM). Allopathic graduates are more likely to pursue residency training in one of the specialties of medicine, while TCOM graduates have a greater orientation toward primary care. On review of the Plan, several issues have been recognized:

The shortage of physicians, both locally and nationally, will not be resolved rapidly by training more medical students. A more immediate solution would be to develop additional graduate medical education (GME) positions, which is where the “bottleneck” in the training pipeline is most acute. This is especially true in Texas, where there are more medical school graduates today than there are entry-level residency training positions, thus forcing Texas medical school graduates to leave the state for residency training and reducing the likelihood that they will return to Texas for their medical careers. In addition, TCOM is a highly regarded school, turning out students who acquit themselves well in osteopathic and allopathic residencies and on the licensing examinations and most of whom embark on careers in Texas.

The Plan’s program and timeline appear to have been given considerable thought, with attention paid to accreditation requirements and processes. However, it appears to us highly unlikely that a UNTMD program could bring all of the pieces together to achieve accreditation and recruit and select students so that a first-year class could commence medical studies in 2013. For example, early recruitment of senior leadership is critical. Unless all are internal candidates, recruitment will be time-consuming, likely more than allowed in UNTMD’s aggressive timetable. If the senior leadership are internal candidates, however, their transfer to UNTMD will impact the existing programs of UNTHSC and TCOM.

Report to TOMA: Development of an Allopathic Medical School at UNTHSC February 7, 2011

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The Plan’s financial projections also present a highly optimistic view of the economies that can be achieved by establishing a new school on UNTHSC’s existing campus. Faculty and administrative costs may be underestimated and the projections assume that existing UNT staff will take on significantly more responsibility at no direct cost to UNTMD. State per capita support and tuition revenues are projected to provide nearly $11 million to support the proposed school’s $16.8 million in direct operating cost in the first two years of the program, but are dependent on recruiting the full maximum class of 100 students in the first year – unusual and extremely difficult given the projected timing of accreditation and infrastructure development. Over the first eight years of UNTMD’s operation, the Plan projects it will require and receive State payments of $105.8 million. Further, the pledges made by hospitals toward starting a new school may be tenuous, given the deficits in federal and state budgets that finance Medicare and Medicaid, two major sources of hospital funds. Finally, while building a new school on an established campus can yield some economies, the track record of other medical schools that have been recently developed indicates that their costs have been in the range of four times the amount set forth in the plan for UNTMD.

Commitments to maintain the integrity of TCOM as the new allopathic school develops are part of the Plan. However, while initial commitments were made to obtain support for the Plan from the osteopathic profession, both the American Osteopathic Association and TOMA passed resolutions in opposition prior to the UNT Regents’ consideration of the proposal in August 2010. The enforceability of the promises made concerning TCOM is unclear at best, and regardless of the effort to ensure cooperation between the schools there inevitably will be competition for existing and potential new resources between TCOM and a new allopathic school that will only be heightened if the initial projections for UNTMD prove, as we expect, to be overly optimistic.

Given these realities, our recommendation would be for TOMA not to endorse the proposed new medical school. Instead we would advise working with the local and state-wide leadership in medical education to develop new or expanded programs at the GME level, which is the priority identified by the Texas Higher Education Coordinating Board (THECB) and the Texas Medical Education and Physician Workforce Consensus Group. For GME expansion, an MD-granting medical school is not required. Providing more opportunities for the medical students already graduating from Texas medical schools (educated in part at State expense) to stay in the Metroplex for their residencies will achieve more directly and quickly the benefits the UNTMD Plan seeks to achieve.


REPORT TO THE TEXAS OSTEOPATHIC MEDICAL ASSOCIATION ON DEVELOPMENT OF AN ALLOPATHIC

MEDICAL SCHOOL AT THE UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER

Background and Questions for this Review

The Texas College of Osteopathic Medicine (TCOM) is a well-established and highly regarded osteopathic medical school in Fort Worth. It is accredited by the Commission on Osteopathic College Accreditation (COCA), the organization recognized by the U.S. Department of Education for accreditation of osteopathic medical education programs, and is a part of the University of North Texas Health Science Center (UNTHSC). Its programs have educated many of the primary care practitioners in the Fort Worth area and beyond. Given the growing awareness of a physician shortage, especially in the primary care and generalist disciplines, UNT’s and TCOM’s strategic goals over the next several years include expanding TCOM’s enrollment to 230 students per year. There also has been discussion over the past several years about whether there is a further need to develop an allopathic medical school in Fort Worth and whether such a development would have advantages for UNT, area providers, and the Fort Worth community more generally. Leaders at UNT and in the Fort Worth community have developed a proposal for creating a separate new allopathic medical school – “UNTMD” – to educate an additional 100 students per year beginning in 2013 in conjunction with and running parallel to TCOM.

The “Academic and Business Plan for the Development of a Proposed MD Program” (“the Plan”) has been approved by the UNT Regents for further development and implementation1 but requires a range of approvals and actions before moving forward. In particular, the Plan is built around the elements necessary for accreditation by the Liaison Committee for Medical Education (LCME). This organization, jointly managed by the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC), establishes strict standards for the curriculum, facilities, faculty, and finances that are the infrastructure for allopathic medical education programs. More generally, the Plan describes elements of distinctiveness of the proposed UNTMD program as a rationale for developing a separate allopathic medical school within a general framework of maximizing sharing of faculty, facilities, and infrastructure on the UNTHSC campus to reduce the costs of developing and operating the proposed school.

The tension between the argument for the distinctiveness of the proposed school and the plans for maximum sharing of resources is evident throughout the Plan: If UNTMD is developed to be distinctive and meet the LCME’s accreditation requirements, can it meet the goals for development speed and budget frugality it has set without prejudice to

1 Action at the UNT Regents meeting of August 19, 2010.


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TCOM? If it meets its goals for development speed and budget frugality, can it achieve its goals for distinctiveness, which are important to its rationale for why it should be developed as a parallel school, for recruiting faculty and students, and for meeting accreditation requirements?

This Report This report examines UNT’s Plan, focusing on two distinct but overlapping sets of issues:

1. The adequacy of the planned organization, facilities, faculty, and curriculum of the new allopathic school and its development timeline, especially in comparison to the accreditation standards established by the LCME; and

2. Financial projections for the development, start-up, and operation of a new school of medicine, in light of UNT’s business plan, the opportunities and difficulties of sharing resources, and the very recent experience in Texas and elsewhere with the development of several new medical schools.

In preparing it, we have reviewed the Plan and accompanying August 2010 “High-Level Costing Model” in depth in light of our collective 50 years of experience2 in developing and implementing plans for undergraduate and graduate medical education programs in Texas, California, and at the national level as well as in conducting accreditation reviews. We also have interviewed knowledgeable individuals from the DFW Metroplex and beyond, most of whom were at least somewhat familiar with the UNTMD plan.

After a brief summary of trends in allopathic and osteopathic medical education nationally and in Texas and the LCME accreditation process that provide a context for UNTHSC’s Plan, we discuss key elements of the academic program, facilities, and financial elements of the Plan.

Medical Education in Texas

Medical Schools in the United States, Allopathic and Osteopathic There currently are 133 accredited allopathic medical schools awarding the M.D. degree in the United States, including seven that are “in development” having been granted “Preliminary Accreditation” status. (See further discussion in the section on LCME below.) They are in 45 states and in Puerto Rico. Texas has eight schools, including the Paul Foster School at Texas Tech University in El Paso, which is on Preliminary Accreditation status. Seven other schools nationally, but none in Texas, are in the initial “Applicant” status in the accreditation process. One additional school is a “Candidate” school – the stage preceding Preliminary Accreditation.

2 See author biographies, Appendix A.



There currently are 26 colleges of osteopathic medicine awarding the D.O. degree, offering instruction at 34 locations in 25 states. The University of North Texas Health Science Center Texas College of Osteopathic Medicine in Fort Worth is the only osteopathic medical school in the State.

As discussed in the UNTMD Plan, with the current perception that there either is or will be a shortage of physicians in the U.S., particularly those in the generalist or primary care disciplines, there has been pressure to increase enrollment in medical schools, both by expanding class size in existing schools and by expanding the number of schools. The Association of American Medical Colleges (AAMC), for example, has called for a 30% increase in the number of graduates (currently around 16,000 per year in the U.S. from allopathic schools) by 2020, and the American Association of Osteopathic Colleges of Medicine (AACOM) projects a roughly parallel growth in number of graduates, which given the smaller number of osteopathic than allopathic schools yields a significantly higher rate of growth.

Several challenges stand between achieving this growth in medical school enrollment and achieving its intended effects. One challenge is to orient students toward primary care, as only about 25% of allopathic medical school graduates wind up in these disciplines after finishing their training. It would seem paradoxical that the Plan actually calls for students from UNTMD to follow the example of MD graduates elsewhere and favor training in one of the subspecialty services, not primary care, which is where the shortage is most acute. A recently reported study showed that Texas in 2008 had the second lowest ratio of primary care providers to population in the nation – 30% lower than the average of the 50 states.3 A second challenge is to induce these graduates to practice in currently underserved areas – most of them rural or inner city communities. Third, and underlying the previous two, is the tremendous debt load with which students graduate, not uncommonly exceeding $200,000. Fourth, and most pressing in Texas, is the limited number of residency positions available to medical school graduates, which has not been increasing commensurate with the increasing number of graduating medical students and is limited by caps on federal support for graduate medical education. (See below.)

There has been growing convergence between allopathic and osteopathic medical education, so that the educational programs are looking increasingly similar. For example, research expansion has been an important priority at TCOM. Allopathic and osteopathic graduates are accepted into residency programs, research grants are available to both, and public and private insurance plans make no distinction between physicians who are graduates of osteopathic versus allopathic medical schools. A distinct philosophy of medicine is at osteopathy’s roots, one that emphasizes care for the whole individual in his/her social environment and other elements particularly important in primary care, as well as the techniques of osteopathic manipulation. While calls for further coming together have been published in medical journals including Academic Medicine

3 Leighton Ku, et.al., “The States’ Next Challenge – Securing Primary Care for Expanded Medicaid Populations.” New England Journal of Medicine Online First, 10.1056/NEJMp1011623 downloaded from nejm.org January 27, 2011, Table A.1



(published by the AAMC), differences between the two modes of education have been cited, including by the leadership both of the LCME and the osteopathic profession, as reasons to maintain parallel tracks.

The LCME Accreditation Process Accreditation of allopathic medical schools in the United States is under authority granted by the U.S. Department of Education to the Liaison Committee on Medical Education (LCME). The LCME is an organization jointly managed by the American Medical Association and the Association of American Medical Colleges. Each of those organizations appoints a senior staff person as Secretary of the LCME, and the Secretariat alternates each year between the two LCME Secretaries.

The LCME publishes the standards for medical school accreditation as The Structure and Functions of a Medical School, a well-organized document but one that is also challenging to understand and interpret. However, the LCME Secretaries in general are very helpful both to established and proposed schools in interpreting the intent of the standards. The standards also undergo regular review and revision.

The LCME emphasizes that it accredits “programs," not schools. In reading through the documents, it is clear that the principal intent is for there to be a well-designed and well-executed program that supports student education in a scholarly environment.

A separate document issued by the LCME, Guidelines for New and Developing Medical Schools, outlines the standards and process for starting a new school of medicine. New schools face challenging standards that must be in place prior to the initial application for accreditation. Personnel and agreements must be in place and initial documentation submitted for a proposed school to move from Applicant to Candidate status. Under the LCME standards, new schools may not advertise for applicants in any manner while in either Applicant or Candidate status. Moving from Candidate to Preliminary Accreditation status requires submission of extensive documentation of the program’s infrastructure and curricular plans, the so-called Self Study, followed by a site visit scheduled according to LCME’s calendar. The LCME holds two-day meetings three times a year, usually in October, February, and June, to make decisions concerning accreditation and re-accreditation. The information gathered through the self-study and site visit is reviewed by the LCME and Preliminary Accreditation possibly granted. Only then may a first class of students be recruited, selected, and matriculate – a process that itself requires nearly a year after the LCME grants Preliminary Accreditation. A second set of detailed materials, site visit, and LCME action is required at the mid-point of the charter class’ second year in order to continue Preliminary Accreditation and allow the students to continue into the clinical years of their MD training. Programs subsequently are reviewed at the time that the first class enters their fourth year, and if the program is deemed worthy the LCME grants full accreditation.

http://www.lcme.org/procedur.htm#quarterly%20meetings



A chart comparing the LCME standards, based on the most recent (2010) revision of the Structure and Functions document, with the UNTMD Plan for its medical school is included as Appendix B. Exhibit 1 highlights those requirements that would be especially challenging to complete in the short time frame suggested in the Plan.

Exhibit 1 MAJOR LCME REQUIREMENTS NOT ADDRESSED IN THE UNTMD PLAN

LCME Section

Requirement

Comment

IS-8 Appointment of the medical school dean

This cannot officially begin prior to legislative approval of the MD program. Recruiting someone, especially if from the outside, may take six months or more.

IS-11 Appointment of Associate Deans, Dept. Chairs, etc.

Also likely to take significant time -- after the dean is in place. Also, recruitment of academic leaders and senior faculty can be very expensive.

IS-12 Establish clinical settings with GME and CME

While not required with the initial class, the time needed for new GME program approval may be up to two years.

ED-1 Faculty defines overall objectives for the educational program

This must be the role of the UNTMD faculty (recruited and appointed after the Dean and other UNTMD academic leaders), not the TCOM faculty.

ED-24 Residents must be familiar with educational objectives and prepared as teachers

Not required with the initial class, but of critical importance. The UNTMD academic program as outlined depends heavily on new residency programs, leaving much doubt about the rapidity of realizing it.

MS-23 Effective financial aid and debt management counseling

Not clear where this will “live.” Assigned to Director of Financial Aid but this position is not budgeted for the initial application year.

FA-2 Sufficient numbers of faculty to meet the needs of the educational program

See notes for IS-11 above. The Plan for clinical education depends heavily on part-time community faculty physicians whose commitment to UNTMD is not documented in the Plan and an unknown proportion of whom currently may have responsibilities educating TCOM students.

ER-2 Adequate present and anticipated financial resources

As noted elsewhere, there are questions about the adequacy of the financial models presented.

ER-6 Appropriate resources for clinical instruction

The plan depends on using both existing and new hospital settings with existing or new residency programs. There is already a mismatch between the number of medical school graduates and entry GME positions in Texas, which would be made worse by adding of UNTMD.

As can be seen, numerous essential activities must take place prior to the development of an application for preliminary accreditation that are not addressed in the Plan or will require significant time to undertake if the Legislature gives UNT authority to develop UNTMD. The appointment of



a medical school dean, especially from outside of UNT and especially if the candidate is a savvy negotiator, could take months to complete. The development of clinical sites, with respect to facilities, clinical teachers and residents, is another major challenge given the timeline necessary for development and accreditation of a GME program where none exists today as well as the contemporary pressures placed on medical faculty in the clinical departments that necessarily limit their commitment to medical education. Schools in Development, and the LCME Accreditation Timetable Moving from Applicant to Candidate to Preliminary Accreditation status has been a lengthy process for most schools currently in development, as shown in Exhibit 2.

Exhibit 2

Applicant Institution Location June 2008 January 2010 October 2010Scripps SoM La Jolla, CA Applicant School Withdrawn?? Withdrawn*Oakland University William Beaumont SoM Rochester, MI Applicant School Candidate School Preliminary AccreditationTouro University CoM Hackensack, NJ Applicant School Applicant School Withdrawn**Hofstra University SoM Hempstead, NY Applicant School Applicant School Preliminary AccreditationVirginia Tech Carilion SoM Roanoke, VA Applicant School Preliminary Accreditation Preliminary AccreditationThe Commonwealth Medical College Scranton, PA Candidate School Preliminary Accreditation Preliminary AccreditationFlorida International University CoM Miami, FL Preliminary Accreditation Preliminary Accreditation Preliminary AccreditationUniversity of Central Florida CoM Orlando, FL Preliminary Accreditation Preliminary Accreditation Preliminary AccreditationPaul L. Foster SoM - Texas Tech University El Paso, TX Preliminary Accreditation Preliminary Accreditation Preliminary Accreditation

Northern Ontario SoMThunder Bay / Sudbury, ONT Provisional Accreditation

To be surveyed 2011-12 for Full Accreditation

To be surveyed 2011-12 for Full Accreditation

University of California, Riverside SoM Riverside, CA Applicant School Applicant SchoolCentral Michigan University SoM Mount Pleasant, MI Applicant School Applicant School***Cooper Medical School of Rowan University Camden, NJ Applicant School Applicant SchoolQuinnipiac University SoM North Haven, CT Applicant SchoolPalm Beach Medical College Palm Beach, FL Applicant SchoolWestern Michigan University SoM Kalamazoo, MI Applicant SchoolUniversity of South Carolina SOM, Greenville Greenville, SC Applicant SchoolFlorida Atlantic University CoM Boca Raton, FL Candidate School

Sources: LCME and Institution websites.

** Touro College now completing affiliation with New York Medical College; Touro will appoint NYMC Board of Trustees.*** Central Michigan University press release, 12-15-2010 (Not yet shown on LCME website

* December 2010: The Scripps Research Institute will affiliate with Florida Atlantic University's Medical School, which has separated from University of Miami

Medical School Development Proposals in the LCME Accreditation Pipeline 2008-10

Site visits are a central part of the accreditation process; they require the LCME to assemble accreditation staff from a range of disciplines. In many cases site visit scheduling has required from three to six months’ lead time following submission and review of the required self-study material. Additional time is required for the visitors to develop and agree on their report, for the Secretariat to review it and schedule its review by the full LCME, and for the LCME to grant the approval.

As noted in UNT’s Plan, in Texas two factors beyond the LCME timing affect its ability to achieve the timetable it has set for developing UNTMD and matriculating a first class of 100 students in August 2013.

The first is critical to the beginning of the process. The University of North Texas Board of Regents currently is prohibited in Texas state law from offering programs leading to



the MD degree. Providing that authority will require an act by the Texas Legislature during its current session, before May 2011. The Texas Higher Education Coordinating Board (THECB) would be requested to comment on the proposed bill as a part of the legislative process. THECB’s analyses show that development of additional residency programs and positions would be the most important actions for increasing the supply of new physicians practicing in Texas. A two-thirds legislative majority is required for laws to take effect immediately on the Governor’s signature; otherwise they become effective 90 days later or on the first day of September. As of the date of this report, no legislation had been introduced to remove the prohibition, and THECB has not been requested for comment.

The second factor is the timetable for applications to medical schools in Texas through the Texas Medical and Dental Schools Application Service (TMDSAS), in which all Texas medical schools participate. The process begins in May of the year before the year in which applicants are accepted and matriculate. For UNTMD to participate fully in the TMDSAS process and matriculate students in August 2013, it would need approval to recruit its first class before May of 2012 – not possible according to the LCME timetable as described above and in the Plan. As projected in the Plan, a June LCME approval would require a special TMDSAS alert to students who already may have begun the application process, who could revise their applications to include UNTMD. Due to the LCME’s prohibition of any recruitment of students before the accreditation decision, however, UNTMD would have little time to advertise widely information about the new school or do any outreach for that purpose. For any later LCME approval, UNTMD would need to follow a separate application process. Time for candidate interviews would be tightly compressed. While possible, in either case the timing of the application process would make it very difficult for UNTMD to matriculate a first class of 100 from among the most highly qualified candidates.

Summary Observations and Conclusions – Medical Education, the Plan, and LCME Accreditation The LCME accreditation process is long and tortuous. It is not possible to accelerate

it, and patience and great attention to detail is required.

Much of the program leadership has to be in place before an application for accreditation can be submitted. This includes the Dean, senior staff, and core faculty. Unless all are internal candidates, recruitment is likely to be time-consuming, perhaps more than allowed in UNTMD’s aggressive timetable, and more expensive than planned. If the senior leadership are internal candidates, their transfer to UNTMD will impact the existing programs of UNTHSC and TCOM.

Much thought has gone into the UNTMD proposal, and it is likely that the planners have received some advice and guidance from the LCME. However, as shown in Exhibit 1 and Appendix B, much work needs to be done to bring the plans to the point that they can be submitted as an application for Preliminary Accreditation. Given the history of other schools in development, submitting the application within six months of the arrival of a dean is highly aggressive, and the lead times for LCME action to



review the material and grant the initial site visit and then to act on the site visit report and grant Preliminary Accreditation also are compressed. To achieve all of this so that a new class can matriculate in the fall of 2013 would seem highly unlikely.

Medical Schools and GME Graduate Medical Education (GME) is the training that takes place after graduation from medical school and that focuses on clinical training in one of the specialties of medicine. This is also known as residency and fellowship training, and it lasts from three to seven years. The Accreditation Council for Graduate Medical Education (ACGME) accredits allopathic GME programs; osteopathic internships and residencies are accredited by the American Osteopathic Association (AOA). Some programs, including ones in Fort Worth, are dually accredited, and ACGME-accredited programs are open to osteopathic medical graduates.

GME programs generally are sponsored by hospitals or health systems, and residents serve in both inpatient and outpatient settings. GME is largely financed by hospital revenues, which are supplemented and largely underwritten by payments from the federal Medicare program. Medicare spent approximately $11 billion in 2010 under specific programs that support GME activities in residencies accredited by either the ACGME or AOA. Historically, Medicaid programs also contributed to the support of GME as part of their payments for patient care. However, Texas eliminated GME funding through its Medicaid program several years ago. In addition, in recent years there has been a cap on how many positions the Medicare program will support, and new GME programs or positions have been difficult if not impossible to fund in this way.

Both the ACGME and the LCME cite the requirement in their standards that residents serve as teachers. The LCME specifically requires that students have a component of their education and training in the presence of residents.

In Texas, there are more medical school graduates than first year residency positions. In 2010 there were 1,404 graduates of the State’s medical schools (including TCOM) and 1,390 entry-level residency positions. The Texas Higher Education Coordinating Board (THECB), the Medical Education and Physician Workforce Consensus Group (in which TCOM and the other medical schools in Texas participated) and other groups have documented this situation and the costs and loss of direct benefits that result, and have recommended expansion of GME as the highest medical education priority in the State. As one medical school leader told us, “We are losing our medical school graduates to California” – after state funds have contributed about $200,000 to the education of each student who must go out of state for residency. This poses significant problems for Texas, since residency location is a stronger predictor of where physicians wind up in practice than either their state of origin or the location of their medical school training. A shortage of physicians in a state or region will not be solved rapidly by the creation of a new medical school, the entering class of which will enter practice no earlier than seven years later. Developing residency programs to allow graduates of existing medical



schools to stay in state and attracting medical school graduates from other states has a quicker “payoff.”

Summary Observations and Conclusions – The Plan and Texas’ Need for GME GME is an essential ingredient in the stew that is a medical school. The current hospital sites used by TCOM for medical student clinical education and that have residency programs may not be able or willing to take on a substantial increment of allopathic medical students. As one hospital’s GME official told us, “If we have to take more medical students for clerkship rotations, we will have to cut back the number of students we train in other areas.” In addition, the sites mentioned in the Plan that currently are expressing interest in new GME programs may well get cold feet due to both the challenge of obtaining accreditation and the uncertainty, to say the least, of receiving any public funding for the significant costs they would incur in sponsoring and operating GME programs.

Additionally, the Plan seems to contain a logic that is difficult to understand: that there is currently a challenge in obtaining residency positions for TCOM graduates, and therefore there is a need for more GME positions in the region, but the development of GME programs by hospitals can only happen if there is an MD-granting school as their academic partner. First, there is no basis in the standards of accreditation or otherwise for this last assertion. Second, from the comments we heard from hospital leaders, the decisions by these hospitals concerning their development of new or expanded residency programs would appear only loosely linked to the development of UNTMD.

Finally, if the “problem to be solved” by development of UNTMD is Texas’ need for physicians, development of GME programs rather than development of a second medical school in Fort Worth would appear to be the near-term priority.



The UNT Plan for UNTMD

Academic Program The plan set forth in the program description addresses both the basic science and the clinical portion of the medical school curriculum, although the document provides greater detail for some critical aspects of the program than others. Some highlights include the following:

Faculty are to be shared in the two schools. The proposed allopathic medical school for the University of North Texas (UNTMD) is basing much of its program on maintaining very close ties with the osteopathic medical school that already exists and with the Graduate School of Biological Sciences, whose faculty now provide basic science instruction for TCOM students. Specifically, the academic program that we have seen documented indicates that "to every extent possible the DO and MD schools should utilize the same organizational structure and personnel…" This includes faculty and administrators, and even a Joint Curriculum Committee (not apparently with final approval authority).

The Plan calls for a "single medical faculty" for the two schools. Yet there also would be separate Promotions and Tenure committees, separate faculty by-laws, and other structures. For the basic science faculty the plan looks for "economies of scale" in combining the faculty. Meanwhile the Plan calls for the addition of 12 FTE (estimated at about 28 new faculty members, many of them part-time) to accommodate the increased teaching demands from medical student education. Clinical faculty will initially be hospital- and community-based. Approximately 14 new FTE will be approved (70 individual faculty with partial support) across the disciplines. However, the mechanics of allocation of the FTEs to departments, both clinical and basic science, is not apparent. The clinical faculty plan does not specify whether the additional clinical faculty would be a mix of physicians new to teaching who would need training on educational methods and evaluation, versus additional time for current TCOM faculty members, which would likely take away time from their clinical practices and potentially from their availability to TCOM students. While the Plan presents evidence of interest from hospitals, it does not have a parallel section documenting the willingness of community physicians to teach in the UNTMD program.

Curriculum. TCOM's Problem-Focused Curriculum is proposed to serve as the model - first year students will receive the bulk of direct teaching in a large-group format. The Plan suggests that "economies of scale" can be gained by combining the DO and MD students.

The "Problem Focused Application" module will be core. This follows the Problem-Focused Curriculum and involves case presentations and analysis and is done in small groups. While this teaching is the same for MD and DO students, its class-size limitations lead to requiring more faculty participation. In the DO program, small group discussion



sessions supplement the large-group lectures. No similar provision is made in the Plan for additional MD or PhD faculty to lead similar sessions for the MD students.

The pledge that UNT has made that TCOM and UNTMD students would receive clinical training in the same settings through a common faculty also could raise dilemmas for individual faculty members: to the extent that the curricular goals and student evaluation requirements of UNTMD differ from those of TCOM, individual faculty may be pulled in two ways in providing clinical instruction. On the other hand, if the curricular goals and evaluation schemas are identical between UNTMD and TCOM, the distinctiveness and need for UNTMD is less clear.

Research. There are suggestions throughout the proposal that there will be curricular offerings, especially in the basic sciences, which will advance a research emphasis for medical students, and that this will be a distinguishing characteristic of UNTMD versus TCOM. The specifics on how this would be done are not provided. In addition, a research faculty is required if there is to be credible mentoring of medical students with research interests. Research faculty depend largely on extramural, i.e. grant, support, with the National Institutes of Health (NIH) being the most recognized and honored source of such funds. Extramural support can be elusive, and it is very difficult for institutions to compete with institutions like Johns Hopkins and UT Southwestern that are already well funded, but UNTHSC has doubled its research revenues in the last several years from a variety of sources and operates the nation’s only federally funded center for osteopathic research. An ambition to grow research programs exists, but the financial plan set forth in the UNTMD proposal includes no faculty positions fully dedicated to research (versus teaching) and little of the required infrastructure for a sustained research enterprise. UNTHSC has submitted a legislative appropriation request (LAR) for funding development of a research building on the UNTHSC campus in the upcoming biennium, but does not stipulate that the request is contingent on approval of development of UNTMD. If the request has been sized based on the projected needs of TCOM and Graduate School of Biological Sciences faculty, if UNTMD is approved the proposed building either will need to be expanded, or the expansion plans of existing UNTHSC units will be constrained by recruitment of UNTMD researchers.

Information Sciences. "Informatics" is an area given special attention in the Plan and would be taught via the library with limited additional staff.

Clinical Training. Clinical training also calls for joint activities between the two schools. There is heavy dependency on hospitals to provide clinical training for students and to provide the faculty for that training. There remains a need to develop a formal curriculum for the "core" clinical areas (family medicine, internal medicine, pediatrics, surgery, psychiatry, obstetrics & gynecology) and agreements for faculty and facilities that would provide for the more than 40% increase in the number of students who would require clinical training in local facilities if UNTMD is developed according to the Plan.



Summary Observations and Conclusions – Academic Program Clearly there has been much thought given to the development of the program proposal for a new school of allopathic medicine at UNT. The academic program has most certainly been tailored to attempt to meet the LCME standards and to be different from the program at TCOM in sufficient particulars to justify its separate development and accreditation while being as frugal as possible. Many details have been necessarily left out. However our review of the UNTMD Plan suggests concerns about several of its elements:

The joint faculty arrangement prescribed may generate “economies of scale” but may also run afoul of the LCME requirements for independence and autonomy of the medical school faculty.

The community-based model of clinical education has worked well for some schools of medicine, but the challenges in gaining and especially sustaining success in such an arrangement are substantial, especially around guaranteeing quality instruction. This approach to clinical education requires recruiting sufficient numbers of voluntary faculty who donate their time or receive some stipend support. Recruiting community faculty and assuring educational quality is made even more challenging by the increasing pressures on practicing physicians for productivity in the face of declining reimbursement and the increasing requirements for direct supervision of trainees, both medical students and residents, in the clinical setting.

The role of GME in medical student education has been under-emphasized, as has the difficulty in developing new residency programs in hospitals currently without GME activities. This is the case related to both the sources of revenues to support GME and the difficulty faced with gaining GME program accreditation.

The difficulty and expense of developing a robust research enterprise is not sufficiently acknowledged. The cost of recruiting a single senior investigator and his or her entourage can easily be well beyond $1 million versus the $750,000 projected in the Plan.

The overarching issue of whether there is now a need for a new medical school in the Dallas-Fort Worth Metroplex has also been called into question by some of those we have interviewed. As one individual in the region who has for a number of years been in senior positions in medical education told us, “We really do not need this medical school here, not at a time when state funds are limited and serious budget reductions are threatened.” With the development of a UNTMD in the Metroplex, along with the expanded enrollment of TCOM and the highly regarded, research intensive University of Texas Southwestern Medical School, the Metroplex would be the area with the highest concentration of medical students in public medical schools in Texas. As the December 2008 report of the Texas Health Policy Council showed, medical schools in Texas enroll more first-year medical students who are from the Metroplex than from any other region in Texas. But the Metroplex has less than half



as many first-year residency positions as the Gulf Coast (Houston/Galveston) region.4 As discussed above, if the fundamental goal is to educate physicians who will meet the future needs of the Metroplex, the focus should be on GME.

Infrastructure and Facilities Plan The Plan proposes to accommodate a 43% increase in medical student numbers on campus without any new building. Renovation of 22,200 square feet of space in facilities vacated by TCOM is planned to provide the lounge space and most, but not all, of the lecture and classroom space required for the UNTMD students, and $1.6 million for these renovations has been included in the financial plan – as an “HSC-wide expense” and therefore not included in the $21.5 million figure the Plan cites as the costs of developing UNTMD. Library and study space in the Lewis Library on campus (which recently added an open floor of study space), along with other buildings on campus, is projected to be capable of handling the large increase in students.

The Plan, however, does not address in detail how it would provide for a number of the other critical facilities required for the new school and its incremental staff. It discusses gross anatomy laboratory and related space, and concludes it is adequate. However, while the staffing plan anticipates that 5 of the 12 FTE additional basic science faculty members will be research faculty and the financial plan projects the recruiting packages for those faculty members will include $250,000 each for lab renovations, the Plan does not discuss where in the existing buildings on campus those labs would be housed. UNTHSC’s planned research building, for which it is seeking legislative funding approval during this session but not mentioned in the Plan, may be sized sufficiently to accommodate an increase in researchers and research-related administrative functions, but the space and cost are not included in the Plan, and accommodating the additional research faculty would be contingent on Legislative authority to construct that additional space.

More generally, the Plan does not discuss where space would be provided for the additional faculty who need to be recruited for UNTMD, who could range upward from 26 FTE to as many as 100 (individual headcount). While individual offices need not be required for all of them and some of the clinical faculty in particular presumably would have space at the hospitals, additional space on campus likely will be needed. Similarly, the Plan does not provide space for the Dean’s office or administrative functions of UNTMD, other than to suggest that they potentially could be located in space built for TCOM and other existing campus programs, which would cramp the potential future expansion of the programs for which the building was built and create pressure for additional building on campus after UNTMD was developed that is not included in the Plan. The Plan’s financial analysis does not include any portion of the development costs of these additional spaces either as up-front costs (as it does treat renovation of the building that TCOM will vacate and UNTMD will use) or show any separate line item for costs of occupancy of the buildings over the eight-year projection period. 4 Texas Health Policy Council, Physician Workforce and Graduate Medical Education in Texas, December, 2008, figures 10 and 13, pps 19 and 21.



Summary Observations and Conclusions – Infrastructure and Facilities Plan The planned space assumes significant sharing, which makes direct comparisons difficult, but appears to leave out provision for school functions that are included in the space inventories of other medical schools in Texas.

Financial Plan The Plan includes as an appendix the “High-Level Costing Model” developed in August 2010, which provides significant detail to support the projected revenues and costs associated with development and operation of UNTMD. The analysis appropriately is presented on a marginal cost basis – attempting to project only the incremental costs and revenues attributable to developing UNTMD. It is clear that economies are possible by developing a new program that would share resources on an existing campus. However, the size of the new program – projected to be a 43% increase in the medical students trained through UNTHSC – raises many issues of “relevant range” in the estimate of incremental activity that could be undertaken by existing campus units without additional cost.

The projected budget of the Dean’s office presents one example. Staffing during the planning period appears especially lean, given the extent of agreements that need to be put into place and documentation that needs to be developed for the LCME accreditation process. Despite the large number of affiliation contracts and program agreements that will need to be put into place to govern the students’ experience in clinical rotations, there is no provision for General Counsel, either as direct staffing or as a specifically allocated expense. Similarly, there is no provision for staff or allocated cost for Operations (human resources, controller, public relations, etc.) all of which will have significant up-front, unique demands on their time to establish the new school. Despite the Plan’s reliance on community physicians as clinical faculty, there is no provision for a director of faculty development to recruit faculty and assure their development as teachers. While the summary financial plan does include UNTHSC’s standard assessment of 35% of UNTMD revenues as “infrastructure costs,” there is no assessment during the planning period when school-specific marginal demands on UNT infrastructure will be highest.

As discussed above, it is likely that significant facility-related costs also are not included in the Plan.

Thus, while we agree that UNTMD may be able to be developed at a cost less than the $100 million estimated by THECB as the cost of developing a new medical school, the net $21.5 million figure cited as the costs of developing and operating UNTMD from inception to “full build out” with 400 students substantially understates the financial commitment that would be required.

The revenue side of the financial Plan demonstrates that UNTMD would not be “costless” to the State general fund: the Plan assumes state funding for the increased number of students, without reduction in statewide per student funding formula that



might be required by the Legislature in the face of State budget shortfalls as the number of students increases at UNTHSC and at other schools statewide.

The projected state payments in the financial Plan also demonstrate the importance of enrolling the full first 100 UNTMD students in 2013: state formula funding is provided during a biennium based on the number of students enrolled at the end of the prior biennium. If UNTMD’s first class is delayed to 2014, it would not receive the $10.6 million in state payments projected for 2014 and 2015. This $10.6 million in revenue is assumed to be received by UNTMD in those years – and without it the net cost of developing UNTMD would rise to $32.1 million, greater than the pledges of private support UNTHSC reports it has received. Similarly, if UNTMD is unable to fill its first class due to a later than projected accreditation decision by LCME, it would receive state payments, but a lower amount than projected. UNTMD’s Plan is unusual in projecting the full 100 students expected to be the maximum size of its future classes are recruited in its first year. Many other schools in development recruit smaller initial classes and expand later ones as the infrastructure for the school develops, procedures become more routine, etc. Tuition revenue also is important to the financial viability of the Plan, and dependent on UNTMD’s ability to reach its target number of students in each year.

Finally, we note that other schools in operation in Texas and elsewhere seek philanthropy and other sources to meet operating as well as capital needs. Against that background it is hard to imagine a UNTMD revenue/cost structure that would produce, as projected in the financial Plan, annual reserves for additional investment without requiring philanthropy.

Summary Observations and Conclusions – Financial Plan The Plan presents detailed financial projections, appropriately constructed on a marginal cost basis. However, costs that would appropriately be directly allocated to UNTMD appear to be left out of the calculations, and the revenue projections assume a timing and level of success in recruitment of students that appears highly unlikely. The estimated net $21.5 million cost for development of UNTMD depends on its receiving $10.6 in State funds in 2014 and 2015, which itself depends on the School’s ability to recruit a full class of 100 to matriculate in 2013.



Conclusions and Recommendations

The University of North Texas has set forth an ambitious plan to develop and open a new allopathic medical school matriculating 100 students per year beginning in 2013. This new school would be linked to the existing, well-regarded Texas College of Osteopathic Medicine. The UNT Regents have approved the Plan, as well as specific provisions that are meant to protect the interests of the osteopathic school, although these provisions have not satisfied the concerns of the osteopathic profession nor are they clearly enforceable. Much thought has gone into the program plan, with attention to the broad issues of medical education in a setting that nurtures students, addresses both primary care and specialty careers, and supports research.

However, the Plan includes timelines and financial and facility plans that we believe are at best challenging and may be unrealistic. This begins with the permissions that need to be granted by the Texas Legislature and the Texas Higher Education Coordinating Board before anything else of substance can done, and goes through the process of receiving accreditation by the LCME, the recruitment of deans, other leaders, and core faculty, and the application process for admitting new students. While some economies are generated through the sharing of faculty and space, the overall financial plan is priced well below what recent experience with building such an enterprise in Texas has been.

Given that at least to date no legislation has yet been proposed that would give UNT permission to develop a program leading to the M.D. degree, there is likely to be a significant delay in realizing the Plan that the Regents approved.

There are three major conclusions we would draw from our review:

1. There is no immediate need for an allopathic medical school in Fort Worth, given the greater need for graduate medical education positions and the opportunity to expand the output of TCOM, both of which would do more and more quickly to answer Texas’ need for primary care physicians.

2. The time course for development of a new school has been substantially underestimated. Given the time needed for the administrative and other arrangements that take precedence over admitting students, it may require an additional one-to-three years for the first class to matriculate if the University were to go forward with the plan for an allopathic medical school.

3. The financial plan is underfunded. Even with the economies that could be realized due to shared physical and personnel resources, it is difficult to see how a new medical school could be developed at this cost, which is but a quarter of the estimates made by the Higher Education Coordinating Board and which has been the experience elsewhere in Texas. With the State of Texas already facing a $27 billion deficit in its current legislative biennium, a funding shortfall in the plan for UNTMD would be difficult to make up from public sources and could severely compromise the viability and quality of the education program.



These conclusions apply now and into the foreseeable future. For them to change, we believe the following conditions would be required:

The priorities for medical education set forth by the THECB and others for GME development and for schools in other regions of the state would have been met.

The Texas legislature would be able to commit to ongoing support to funding additional student positions without a commensurate decrease in formula funding for current positions.

The availability of primary care physicians in shortage areas had been adequately addressed.

Based on these findings, we would make the following recommendations:

1. The Texas Osteopathic Medical Association (TOMA) should not endorse the plan approved by the University of North Texas Regents to develop a new allopathic medical school.

2. TOMA should work with the TCOM and UNT leadership, as well as with the leadership of teaching hospitals in the Metroplex, the University of Texas health leadership, and the legislature, to expand opportunities in graduate medical education programs. This would include both increasing available residency positions for osteopathic school graduates and increasing the overall GME enterprise in the region and the state, especially those GME programs that prepare trainees for primary care practice.


JMWatt Consulting ● Altman A.1

Appendix A

Author Biographical Information

David Altman, MD, MBA. is a medical executive with over 30 years’ experience as a chief medical officer in public teaching hospitals, dean of a geographically separated medical school campus, health policy and management consultant, practitioner, medical educator and LCME accreditation site visit member. Dr. Altman received his residency training in internal medicine and gastroenterology at the University of California Medical Center in San Francisco. While a member of the faculty at UCSF, he also served for ten years as the school's Associate Dean and attained the rank of Professor of Clinical Medicine. In 1989, he was appointed as Associate Dean and Director of the University's Medical Education Program in California’s Central San Joaquin Valley, overseeing medical training programs which were aimed at addressing the chronic shortage of primary care physicians in the state’s rural areas. In this capacity he worked closely with many of the community hospitals in the region and maintained an active clinical practice at UCSF. In 1992-93 he was a Robert Wood Johnson Health Policy Fellow and under the auspices of this program served on the legislative staff of Senator John D. Rockefeller IV of West Virginia. He was also a member of working groups of the White House Task Force on Health Care Reform in 1993. As Associate Vice President for Medical Education, from 1994-1996 Dr. Altman launched the AAMC’s Generalist Physician Initiative. From 1996 through 2000 Dr. Altman was a vice president at The Lewin Group, where he led projects related to strategic planning, hospital and academic medical center consolidations, physician compensation arrangements, physician-hospital relations, and graduate medical education. He directed the project to develop the Harlingen proposal for the RAHC. From 2001 through 2004 he led clinical and academic programs as Chief Medical Officer at the Los Angeles County-USC Healthcare Network, a 1350-bed academic hospital system. From 2004 through 2008 Dr. Altman was Chief Medical Officer at Alameda County Medical Center, an integrated health care system that is Oakland, California’s leading trauma center. He currently serves as Regional Medical Director for the Central California Alliance for Health, the Medicaid managed care organization serving 200,000 residents of Santa Cruz, Monterey, and Merced counties.

J. Michael Watt, MBA is President of JMWatt Consulting, an independent consulting practice he established in May 1999 that specializes in planning, financial analysis and management assistance for healthcare institutions. Over the last 30 years, his consulting practice has focused on strategic planning and inter-institutional relations projects for the top management and boards of health care institutions and medical schools. He recently led development of a report outlining a multi-year plan for developing the University of Texas-San Antonio’s Regional Academic Health Center into a four-year medical school and Health Science Center. Previously, with Dr. Altman, he assisted the community of Harlingen, Texas, Valley Baptist Medical Center and Su Clinica Familiar in developing the proposal that led to the development of the RAHC in the Lower Rio Grande Valley and subsequently assisted in developing the affiliation agreement between the UTHSCSA and VBMC, the ACGME-accredited internal medicine residency program, and proposals for state and Medicare funding for RAHC programs. In projects for the Santa Clara Valley Health and Hospital System since 2000, he led development of strategic business plans; facilitated planning for expansion of


JMWatt Consulting ● Altman A.2

SCVHHS’ system of community based primary care clinics and incorporating medical home principles into their organization and operations; and assisted in development of plans for replacement of inpatient facilities to meet California seismic safety requirements. He also has assisted a number of federally qualified health centers in a variety of planning projects. Before establishing JMWatt Consulting for 12 years he directed projects as a Vice President of The Lewin Group, a national health policy research and management consulting firm. He led strategic planning studies for academic health science centers, urban public hospitals, community hospital systems and research institutes. In projects focused on medical education, he led Lewin’s studies of geographically separated medical school campuses and the costs of limits on resident work hours, and facilitated development of GME consortia in Phoenix and Fort Worth. Subsequently, the Phoenix GME Consortium became part of the University of Arizona’s two-year geographically separated medical school clinical education program in Phoenix, which recently enrolled its first class as the University of Arizona College of Medicine at Phoenix, now a full, four-year medical school.

Appendix B February 7, 2011

ELEMENT REQUIREMENT1 m/s2 UNTMD PLAN vs. LCME Requirement

I. Institutional SettingA. Governance and Administration

Part of an accredited (m), not-for-profit (s) institution with formal delineation of the relationship

m/s relationship with UNT fulfills standard

By-laws govern faculty, executives, and governing board

m relationship with UNT fulfills standard

A qualified dean with access and clear lines of authority

m to be recruited

Appropriate associate and assistant deans, department chairs, other leaders, and staff

s to be recruited and relationships with TCOM determined. Proposal suggests some parallel positions, some unified

Charter key committees m to be completed

B. Academic EnvironmentComponent of a university offering other graduate and professional degrees

s planned, contingent on authorization by Legislature and approval by THECB

Clinical settings with GME and CME s not yet completed, although commitments supposedly have been made by various clinical entities in Fort Worth area; few GME programs currently accredited and in operation. Hospital interest in expanding GME described as their primary interest in UNTMD proposal.

An environment of a "community of scholars" m to be developed

APPENDIX B

2m="must" s="should"

LCME REQUIREMENTS FOR ACCREDITATION OF A FOUR-YEAR SCHOOL OF MEDICINEASSESSMENT OF THE PROPOSAL FOR A NEW SCHOOL OF MEDICINE AT THE UNIVERSITY OF NORTH TEXAS

1from LCME, Functions and Structure of a Medical School, 2010 (bold=requirements for LCME consideration of new medical schools)

JMWatt Consulting ● Altman Page B.1



Opportunities for students in research, other scholarly activities, service-learning

s to be developed; scholarly activities, research at UNTHSC are centered in the Graduate School of Biological Sciences. Current activities in the osteopathic medical school are less than at many allopathic schools

Policies and practices to achieve diversity: students, faculty, staff

m Mission statement commits to diverse student population mirroring that of Ft. Worth, and Plan calls for a Director of Diversity Programs. But no such position is identified in the 8-year table of staffing in financial model.

II. Educational Program for the M.D. Degree

A. Educational ObjectivesFaculty defines overall objectives for the educational program

m not clear in plans

A working plan for the curriculum as a whole

m exists, but relationship to TCOM's existing curriculum not clear.

Objectives stated in outcome-based terms that allow assessment of developing competencies

m to be done

A system of central oversight of the program and settings and faculty monitoring of student progress

m to be done. Relationship with existing TCOM systems and staff a critical & unclear factor.

Objectives known to all involved in or responsible for student education

m to be done. Relationship with existing TCOM systems and staff a critical & unclear factor. E.g., proposed shared clerkships will be difficult for supervising faculty if learning objectives are different

1. General DesignAt least 130 weeks of instruction m to be done

Program includes: active learning and independent study m not addressed

current concepts in basic & clinical science m in plan

fundamental principles of medicine m in plan




Comparable educational experiences and methods of evaluation across sites

m addressed In program plan as a goal

2. Content While the proposal addresses many of the issues that are important for accreditation, the level of detail is not that which is required for accreditation.

Includes behavioral and socioeconomic content

m in plan

Full spectrum of basic sciences (m), including laboratory experience (s)

m/s in plan

Clinical instruction in all organ systems; experience in primary care; experience in both outpatient and inpatient settings

m in plan

Clinical experience across array of core disciplines

s in plan

Multidisciplinary content areas (e.g., ER, Geriatrics)

m in plan

Basic principles of clinical and translational research

m in plan

Instruction in communication skills, medical consequences of common societal problems, cultural diversity, gender and cultural biases, medical ethics

m in plan

C. Teaching and Evaluation

Residents familiar with educational objectives and prepared as teachers

m limited current GME programs, and no discussion of the planning and budget needed to develop them.

Faculty supervise learning experiences and have a system of evaluation across knowledge, skills, behaviors, and attitudes

m Plan for supervision and evaluation to be developed. See comments above about plan assumptions about shared TCOM/UNTMD supervision

Evaluation of problem solving, clinical reasoning, and communication skills

m not addressed

Course and clerkship directors have system of m not addressed




Students evaluated early enough to allow for remediation

s not addressed

Evaluations include narrative component s not addressed

D. Curriculum Management1. Roles and Responsibilities

Integrated institutional responsibility for overall design, management, and evaluation of curriculum

m in plan, but relationship to TCOM to be developed . Staffing plan does not provide an Assoc Dean for Med Ed

Chief Academic Officer with resources and authority

m in plan

Faculty committee monitors courses, works with course leaders and administration re time in courses and total required hours

m in plan

2. Geographically Separated Programs

Chief Academic Officer responsible for program at all sites; site director responsible to medical school's Chief Academic Officer

m N/A

Single standard for promotion and graduation of students

m N/A

School responsible for assignment of students (s); students provided with a process to request alternative site (m)

s/m N/A

E. Evaluation of Program Effectiveness

School uses variety of measures including student evaluation of courses, to assess degree to which objectives are being met

m not addressed

III. Medical StudentsA. Admissions

1. Premed RequirementsBroad course of study with limited required courses

s not clear in plan




2. SelectionFaculty committee with responsibility, clearly defined policies and selection criteria

m acknowledged, however questions about whether proposed staff adequate to process expected applications / interviews. Note that TCOM faculty are expected to conduct some UNTMD interviews.

Sufficient pool of applicants m assumed

No political of financial factors in admissions m acknowledged

Programs for diversity, standards for admission of disabled students

m to be done

Informational materials describe programs and school's criteria for selection

m to be done

3. Visiting and Transfer Students

Have comparable experience and achievement to current students

m n/a

Verify credentials of visiting students s n/a

Visiting students possess comparable qualifications to current students

m n/a

B. Student Services1. Academic and Career

CounselingSystems for academic advising and for career choice assistance

m spin-off from TCOM

Residency application not disruptive of education

s n/a

2. Financial Aid Counseling and Resources

Effective financial aid and debt management counseling

m Assigned to Director of Financial Aid (new position). Staffing plan doesn't have position in place during initial application year.




Programs for minimizing effect of educational expenses on debt

s not in plan

Policies for tuition and fee refunds m not in plan

3. Health Services and Personal Counseling

Effective programs for counseling, well-being

m Assigned to Director of Medical Education (new position) Not in staffing plan

Access to preventive, diagnostic, and therapeutic health services, health insurance, disability insurance

m not in plan

Those providing psychiatric care not involved in academic evaluation

m not in plan

Follow guidelines for immunization of students s not in plan

Policies for student exposure to infectious and environmental hazards

m not in plan

C. The Learning EnvironmentNo discrimination based on gender, sexual orientation, age, race, creed, or national origin

m plan needs to be written

Ensure that the environment promotes development of explicit and appropriate professional attributes


Define and publicize standards of conduct for teachers, learners and the teacher-learner relationship and policies for resolution


Publicize to all faculty and students standards and procedures for evaluation, advancement, graduation, disciplinary action





Due process for students subject to adverse action


Student records kept confidential, available to faculty on "need to know" basis


Assure adequate study space, lounge areas, lockers, secure storage

s lounge area from old TCOM building made available; needs to be renovated. Library/study space adequate for proposed class size.

IV. Faculty

A. Number, Qualifications, and Functions

Sufficient numbers to meet the needs of the educational program

m Proposal calls for the two medical schools to share a common faculty , with 12 FTE added the Basic Science faculty and 14 FTE added to the faculty in the clinical departments to accommodate the larger student body. Faculty in the clinical departments is primarily part-time from affiliated hospitals and other organizations; support would be through a combination of medical school stipends and clinical practice. A faculty practice plan is not proposed.

Faculty with capability and commitment as effective teachers

m Faculty recruitment is proposed as a departmental function; separate but overlapping recruitment functions proposed , with oversight by a Promotions and Tenure Committee

Commitment to scholarly productivity s not in proposal

Faculty make decisions on student admissions, promotion, and graduation, provide career and academic counseling

m not in proposal

B. Personnel PoliciesClear policies for faculty appointment, promotion, tenure, and dismissal (m), conflict of interest (s)

m/s Promotion and Tenure Committee to be appointed; would be responsible for policy development




Faculty receive written information about terms of appointment, responsibility, privileges, benefits, regularly scheduled evaluations of performance

s not in current proposal

C. GovernanceDean and committee of faculty determine medical school policies

s as proposed

Full faculty meets regularly to discuss medical school policies and procedures

s not in current proposal. Schools heavily reliant on community clinical faculty have difficulty in making this happen effectively.

V. Educational ResourcesLCME notified of changes in enrollment or resources

m n/a for now

A. FinancesAdequate present and anticipated financial resources for the educational program and achievement of institutional goals

m May be underestimated in proposal; current thinking bases cost estimates on assumptions re: cost savings from shared faculty, facilities. Also may overstate funds available from tuition and state resources.

B General FacilitiesBuildings and equipment appropriate m Plan depends on MD school taking over space vacated by

the DO school, which is moving to new desirable space; the adequacy of that space is subject of a separate section of this report.

Appropriate security systems at all sites s not in current proposal




C. Clinical Teaching FacilitiesAppropriate resources for clinical instruction

m UNTHSC has developed an expanded clinical simulation facility. Other clinical instruction resources depend on hospital affiliates.

Hospital that is major teaching site with appropriate instructional facilities and information resources

m Affiliation with hospitals already engaged in GME is being counted on for instructional facilities as well as faculty. Programs in new hospital affiliates without current GME have not been developed.

Required clerkships in settings where there are residents in accredited GME programs, residents teaching under faculty supervision.

s needs development; it is not clear where the hospitals without currently accredited residency programs are in the process with the ACGME. Those with approved programs do not have the capacity to accommodate all the new students, especially given the provision in paragraph 13 of Appendix A of the Plan, which promises equal access of MD and DO students to clinical training sites.

Written and signed affiliation agreements m Proposal says they are present, but none is specified.

Students at affiliate sites remain under control of the faculty

m Current status not clear. Staffing proposal does not provide a General Counsel resource to develop affiliation agreements.

D. Information Resources and Library Services

Access to well-maintained library and information facilities of sufficient size and breadth, information technology

m This seems adequate. Staffing plan provides 4 additional FTE for informatics and library.

Library and information services responsive to needs of faculty, residents, students

m ditto


Documents

JMWatt Consulting Firm's Report to TOMA on the Proposed MD school at UNTHSC