Long live the veterinary teaching hospital

Distributive model puts profession on path toward economic decline, mediocrity

July 13, 2015 (published)
By Robert Marshak

Twitter photo
Dr. Robert Marshak

(This commentary's original title: "The rise of anti-intellectualism and the decline of quality in American veterinary medical education: its impact and significance")

It is astonishing how swiftly vocationally oriented veterinary colleges have been welcomed and enabled by accreditors and many mainstream academicians, even though these programs exist outside of a biomedical research framework, minimizing the research training of students and utilizing a distributive model of clinical veterinary medical education. 

Equally remarkable is how swiftly a national movement involving many sectors of the profession — practitioners in particular — has mobilized to call for a return to high-quality veterinary education, particularly the teaching-hospital model.

I argue that the proliferation of veterinary colleges with limited or no research base, existing outside of a community of scholars, and pursuing a distributive model of clinical education, not only undermines the fabric of American veterinary medical education but also the economic status and future of the profession.

Advocates vigorously defend distributed learning as a bold educational innovation "aligned with the future needs of the profession and society." I see it as the opposite: a model done on the cheap, highly profitable to its purveyors who need not invest in a teaching hospital while offering the profession an educational approach that is an intellectually impoverished substitute for authentic veterinary medical education.

With one exception (University of Calgary's veterinary college), none of the colleges that lack an academic teaching hospital is located in a research university, and none meets the American Veterinary Medical Association Council on Education’s (COE) accreditation requirement for research activities that integrate and strengthen the professional program. (Editor's note: The COE's research standard is one of several standards that are up for revision by the accrediting body. Written comments regarding proposed changes must be postmarked or emailed to the AVMA by July 23.)

I also believe most are in noncompliance with COE standards 3, 4, 8 and 9. These four standards set minimum accreditation requirements for programs regarding their physical facilities and equipment, clinical resources, and faculty and curriculum.

Absent a teaching hospital and high-impact contemporary research enterprise, distributive-model programs lack a crucially important intellectual foundation that combines teaching and research in a manner adopted by all health professions following the landmark Flexner Report’s critical analysis of vocational medical education. In significant ways, these distributive programs evoke early apprenticeship training models that existed outside of an academic university community and thus threaten to narrow the scope of veterinary medical education, inevitably degrading the stature of veterinarians as co-equal medical professionals within the broader context of medicine and discovery.

The distribution of students for most or all of their clinical training to private practices, which are questionably monitored, puts their clinical education at great risk. This is not owing to a scarcity of private practitioners capable of teaching students many valuable things, some of which they may not encounter in a teaching hospital, but because in their critical third and fourth years, veterinary students require a very different learning environment — one structured to ensure that they acquire the conceptual and intellectual foundations as well as the specific basic skills essential for the practice of veterinary medicine.

As a private practitioner for 11 years and an educator, researcher and dean during the succeeding four decades, I have come to the conclusion that there is no educational substitute for a full-service teaching hospital that integrates teaching, research and patient care. Traditional teaching hospitals also provide students with the following: daily access to a broad spectrum of specialty disciplines; world-class diagnostic imaging equipment; clinical laboratory instrumentation; a necropsy facility; clinical and pathology rounds and conferences that facilitate learning; and interaction with veterinary scientists engaged in high-impact research expose students to the thrill and joy of discovery.

The latter particularly is germane, owing to the increasing complexity of clinical practice at a time of quickening genomic, molecular and translational medicine as well as a widening gulf in knowledge, language and understanding between clinicians and basic scientists.

In the teaching hospital, students are more likely to learn that good medicine means science-based medicine practiced with uncompromising integrity and compassion, and that any lesser standard is synonymous with poor and perhaps fraudulent medicine. A clinical teacher’s primary objective is to prepare students to make their way without them. Because of that, there is a real incentive for clinical educators to encourage students to question and appreciate the dynamic biomedical context of clinical science while learning from failure, becoming skilled at critical analysis and the synthesis of information and appreciating that successful patient outcomes, more often than not, result from collaborations that can cross specialty lines. In the teaching hospital, students are more likely to learn how the three stages of evidence-based medicine are applied and how basic molecular knowledge is transforming clinical practice. In the teaching hospital, students are more likely to confront their own deficiencies. For example, it is possible to do everything medically right and still have a negative outcome.

Today, we live in an age when the practice of medicine is increasingly driven by diagnostic laboratory tests, powerful imaging techniques and expensive therapeutic modalities. It is tempting to cede one’s autonomy to technological devices. It is in the teaching hospital, rather than in a high-volume private practice, that students are most likely to internalize a first principle that must never be abandoned, that barring emergency situations (a cow with acute legume bloat, a dog choking on a bone, a cut artery in a horse), good veterinary care begins with a thorough history and physical examination involving the senses — what one hears, sees, feels and smells. It is in the teaching-hospital environment that students more likely will appreciate that the breathtaking acquisition of new biomedical knowledge means they will be working in a constantly changing environment where they'll need to keep learning. 

Proponents of the distributive model in veterinary clinical education often point to the rotation of medical students through non–university hospitals or physicians' offices as a justification for distributed veterinary education. Two points are relevant here. First, unlike veterinary medical education, human medical education does not lead to clinical certification; all states require that medical-school graduates successfully complete significant additional clinical training before they can be licensed. Thus, distributed-teaching models in human-medical education broaden the exposure of physicians prior to their specialty training often as a way to aid in specialty selection and widen students' exposure to medicine. Second, due to the advanced oversight and regulation associated with human medicine, experience in private or community hospitals generally involves exposure to physicians with advanced credentials and often with academic affiliations or appointments, a broader and more consistent experience than in private veterinary practices.

Having been a clinical department chair and dean in a school with two teaching hospitals, I am well acquainted with the financial burdens they may impose and the one-dimensional argument that they are unaffordable and doomed to extinction. I would counter that a university teaching hospital is an indispensable time-tested crucible for achieving excellence in clinical education and that the distributive model is leading the profession towards mediocrity and economic decline.

As distributive-model schools proliferate, little is heard about the obvious fact that a well-managed campus teaching hospital should be a significant revenue generator. Outpatient clinics and hospitalized patients can generate significant revenues while clinical research programs generate grant and contract research dollars that support faculty and technician salaries while supporting school overhead. Clinical trials, along with advanced veterinary care, can be steady sources of revenue, and endowed professorships for distinguished clinical faculty may free up funds for other purposes. 

Along with adding prestige to the institution, a hospital’s public-service functions (diagnostic, referral, clinical research, and client and professional continuing education programs) attract donors from dog and cat fancies, horse racing and breeding industries, grateful pet owners, individuals with a passion for animal welfare, pharmaceutical companies and alumni. State appropriations also can contribute, especially in support of equine and food-animal research and services. Some veterinary school deans argue that a full-service teaching hospital is unrealistic because the projected case load is too small to sustain it. I believe this is a poor excuse because a good teaching hospital, human or animal, is a precious regional resource. Cornell University's renowned veterinary teaching hospital, located in rural New York, draws clients from across the state and beyond.

In short, I believe the argument that teaching hospitals are unaffordable, and therefore obsolete, is bogus and a disservice to those teaching hospitals that are advancing clinical medicine and financially helping their parent institutions.

Teaching hospitals are powerful magnets attracting the most gifted clinicians, interns, residents, veterinary and graduate students and veterinary scientists. Largely through referrals, teaching hospitals attract the most perplexing clinical cases that are essential to challenging students' ability to develop and work through a differential diagnosis, consult the literature and judiciously use laboratory tests and technical resources.

The abundance of many excellent specialty practices does not obviate the advantages and benefits of the veterinary school teaching hospital experience. However, such practices are excellent sites for carefully chosen student electives that complement a teaching hospital’s program.

Since the fundamental components of veterinary medical education and allopathic medical education, including accreditation standards and the United States Department of Education’s criteria for recognition, are virtually indistinguishable, how is it that so many in leadership positions continue to encourage, and/or accredit schools that do not now, nor likely ever will, meet the COE's published standards?

Enablers, contributors

There have been many enablers of and contributors to the trend toward distributed learning, including the Association of American Veterinary Medical Colleges (AAVMC) and veterinary school deans.

I believe the AAVMC, essentially a deans’ association, has failed to play a proper independent role as an advocate for appropriately rigorous and consistently applied accreditation standards. One reason is almost certainly the fact that the association includes deans from institutions that benefit from weak standards. A second reason appears to be a reluctance to oppose AVMA policies. The result is an organization that justifies the accreditation of schools that fail to meet traditional academic standards while insisting, despite compelling evidence to the contrary, that COE decisions have been "standards-driven and evidence-based."

It is inconceivable to me how the AAVMC North American Veterinary Medical Consortium, which published the 2011 report Roadmap for Veterinary Medical Education in the 21st Century, failed to critically examine the current and long-term impact of the proliferating distributive model on the quality of veterinary clinical education. The report also failed to acknowledge that the COE’s rapid-fire accrediting decisions, domestic and foreign, cemented academic regression.  

Many veterinary school deans whose programs have teaching hospitals contract to provide clinical training for students from incomplete schools and/or schools that fail to meet rigorous academic standards. So there's an incentive for them to enable such schools to thrive while flooding the market with entry-level graduates, most with staggering student loan debt.          

At the December 2014 meeting of the USDE’s National Advisory Committee for Institutional Quality and Integrity, a half-dozen veteirnary school deans, in remarkably similar statements, unreservedly endorsed the COE and its accreditation decisions that have devalued the degrees of graduates and will force their alumni to compete for jobs with a fast-growing surplus of entry-level practitioners. Only two deans (Cornell University's Dr. Michael Kotlikoff and Dr. Joel D. Baines of Louisiana State University) had the insight, long-term perspective and courage to support separating the COE from the AVMA, thus making the accreditating body truly independent. 

Also, veterinary deans have failed to recuse themselves from serving on the COE or from participating in the selection of COE members despite real or apparent conflicts of interest.

Calling for further change

Despite some positive incremental changes, a firewall between the AVMA Board of Directors and COE does not exist. The board has not yet surrendered its practice of appointing the committee that selects COE members. Nor has it provided the COE with its own budget, staff and workplace. In an apparent gesture to appease its critics, the AVMA has offered the COE $10,000 with which to hire its own legal counsel, but those familiar with engaging high-quality counsel will appreciate that this will only buy about 20 hours of legal assistance.

It is time for the veterinary profession to remember and strongly consider the lessons that Abraham Flexner taught to the medical profession. The existence and proliferation of distributive-model veterinary schools that fail to meet traditional academic standards pose a grave and urgent threat to an educational system that, in a span of five decades, had evolved from mediocrity and a trade-school mentality to cutting-edge standing in education, research and clinical practice.

In these advances, teaching hospital clinicians and veterinary scientists led the way by integrating teaching, research and patient care, establishing high-impact comparative and translational research programs, and rapidly developing a broad spectrum of authentic clinical specialties. I believe that the dumbing-down of the educational system with vocationally oriented schools designed only to produce of large numbers of entry-level graduates are a menace to the profession’s future and its reputation as a learned and respected medical profession. Also, such schools have little or nothing to contribute to the urgent global issues of One Health, food-animal production systems, food safety and security, biodiversity, environmental protection, and the advancement of the sciences undergirding human and animal health.

I fear that nothing substantial will be done to stem and remedy this appalling situation without the development of an autonomous, independent and courageous accrediting agency that's separate from the AVMA and AAVMC. This new accrediting body, determined to consistently enforce compliance with toughened standards, must replace the present COE.

Only then will the rising anti-intellectual tide in veterinary medical education begin to recede.

Editor's note: AAVMC Executive Director Dr. Andrew Maccabe, as originally anticipated, will not be providing a counter perspective. The VIN News Service is in search of a replacement. 

About the author: Dr. Robert Marshak is a 1945 graduate of Cornell University College of Veterinary Medicine. In 1956, he joined the University of Pennsylvania School of Veterinary Medicine as a professor and chair of medicine, later becoming chair of clinical studies. His work in bovine leukemia led the National Cancer Institute to sponsor a center for bovine leukemia at Penn's New Bolton Center in 1965. Marshak was named Penn's veterinary school dean in 1973 and spent 14 years in the role. During his tenure, he led the building of a new small animal hospital in Philadelphia and the expansion of New Bolton Center's large animal hospital. He introduced aquatic veterinary medicine at Penn and helped develop veterinary specialties parallel to and in cooperation with those in human medicine. Penn's Marshak Dairy is named his honor. Post retirement, Marshak returned to research and teaching. He resides in Newtown Square, Pennsylvania, with his wife, Margo, who also is an academician and college administrator. 

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