Why paying hospitals for clerkships is good, and necessary

Critics have been making the rounds again with a warmed-over complaint: International medical schools that offer U.S. teaching hospitals financial support for clerkship programs are unfairly buying access for their students instead of “more deserving” U.S.-based students. As the proud dean of a Caribbean medical school, I want to set the record straight yet again: This argument is hollow and based on a false dichotomy. In fact, the argument has long been settled in practice, and here’s why:

Education has a value, teaching hospitals deserve and often need the resources to conduct that education, and we are helping create more training capacity at a time when the physician shortage mandates more resources, not fewer.

To make clinical training possible, an environment must be created that allows for safe patient care in the presence of learners and provides the educational experience necessary for medical students to become physicians. Creating and sustaining this patient and learner-centered environment requires an infrastructure — which in turn requires resources. At American University of the Caribbean School of Medicine (AUC), we believe that the medical education system should provide these resources and not an already drained health care system — one that will inevitably pass costs on to patients or taxpayers or both.

Let me shed some light on how and why we structure our affiliation agreements with hospitals and health care systems. The typical agreement provides resources to pay for the time that the site director and clerkship directors devote to medical education. These physicians take time away from patient care to organize the clinical experience, orient students in the health care system, provide lectures, select physicians to supervise medical students, ensure that supervisors complete student evaluations and work with our university to continually improve the clinical experience.

Affiliation agreements break down the reimbursement per student per week. They may also include provisions for valuable capital resources to renovate libraries, upgrade technologies, improve learning spaces or buy simulation equipment — all of which benefits not only our students but also learners from the U.S. medical schools who rotate through these health care centers. Depending on the needs of the health system, our resources often help to support residency training as well.

In addition to the infrastructure required to create an appropriate learning environment, medical students bring real costs. Teaching medical students slows down patient care. In an outpatient setting, this is typically the loss of revenue from one patient per day or the additional cost of one hour of overtime for staff. In the hospital, many health care providers — such as nurses, pharmacists, social workers, medical translators, as well as physical, occupational, speech, and respiratory therapists — interact with and invest time in medical students. Their salaries are commonly paid by the hospitals and their time is valuable. Medical students also use consumables such as gowns and gloves. They require access to the electronic medical record, which may be an additional cost if access is billed by the user.

These costs stack higher and higher, mounting a serious threat to the financial health of many of the community hospitals that invest in teaching medical students. We believe it is appropriate for a medical school to reimburse health care systems and hospitals for the cost of educating its students.

This logic hardly comes as a shock, which is why U.S. allopathic medical schools, too, have affiliation agreements with the hospitals and health care systems to which they send students for clinical training. These agreements vary widely based on the needs of the U.S. schools and hospitals or health care systems, but money changes hands in many of them. What are people supposed to believe: That because some U.S. educators object to our method, they themselves offer nothing of value to hospitals or health care systems for educating their students?

Lastly, there is a false dichotomy in positing that because international schools help generate and sustain clerkship programs, that means students from U.S. schools have fewer opportunities. In reality, we are adding to the capacity of the medical education system — even helping to expand residency programs while Medicare support is capped. This creates much-needed opportunity for all physicians-in-training at a critical moment. With the well-known provider shortage looming, now is not the time to argue for fewer opportunities.

International medical schools such as AUC provide additional value to the health care system above and beyond support for medical education programs. International graduates join their residency programs, selected by the hospitals in a competitive residency match that includes U.S. allopathic and osteopathic graduates. A large number of our graduates go on to practice in primary care, and many treat diverse communities that are traditionally underserved. They freely elect to practice in these physician-needy communities, despite being kept out of the loan repayment programs designed to attract U.S. graduates to those places. And still they successfully repay their student loans, as evidenced by our less than 1 percent default rate.

We have cracked the code on admitting the kind of students who will choose primary care and practice in underserved areas. We have figured out how to scale our medical school, funneling more graduates into U.S. residencies than any U.S. allopathic medical school. And, we have managed to do it with a sustainable business model – one that does not rely on state taxpayer subsidies for medical education.

Heidi Chumley is executive dean and chief academic officer, American University of the Caribbean School of Medicine.

Image credit: Shutterstock.com

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