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An Essay on Medical Education in Philadelphia 1971-1996

By Fredric D. Burg, M.D.

My immigration east occurred after I arrived in Philadelphia in Oct. of 1970 for an American Board of Family Practice (ABFP) test committee meeting. I had been hired by the American Board of Pediatrics (ABP) to bring advances in evaluation to their certification process. One way to learn more was to work with the National Board of Medical Examiners (NBME) in Philadelphia. The ABP appointed me as their representative to the family practice test committee.

Twenty six years later, I left Philadelphia to take on the job of leading a small community based medical school in Alabama. We are working to develop physicians who will be able to bring healthier communities into the 21st century by applying the traditional biomedical disciplines complemented by informatics, medical economics, bioethics, epidemiology, biostatistics and adult learning.

The goal of this essay is to record my Philadelphia experience by describing some of the changes in medical education that have occurred during the past 25 years. These changes directly involved two Philadelphia institutions, the NBME and the University of Pennsylvania, School of Medicine. I particularly want to describe the impact of three different leaders whom I worked with and how I believe their leadership style influenced medical education not only in Philadelphia, but nationally as well.

My first mentor was John Hubbard who served as president of the NBME for more than 20 years. The second was Edward Stemmler who was dean of the University of Pennsylvania School of Medicine for 15 years. The last is William N. Kelley who has been both dean of the University of Pennsylvania School of Medicine, CEO of the University of Pennsylvania Medical Center and CEO of the University of Pennsylvania Health System since 1989.

A Visionary Approach to Educating Physicians in the Twenty-first Century (1970-1980)

My first job in Philadelphia was as a member of the senior staff of the NBME. John Hubbard asked me to come to Philadelphia after meeting me at the test committee for the new American Board of Family Practice.

John Hubbard, who looked and talked like an American aristocrat (which he was) was a national figure who stood up for his beliefs and used his power to bring about change. In the early 1970’s there were many who believed that Family Practice had no place as a medical specialty. They believed the specialty was too broad in the types of problems and patients the family practitioner would have to manage while the training was not rigorous enough.

John used the office of President of the NBME to champion this new and quite different specialty. John had early on recognized that the country would require more generalists to serve the needs of the people. John led the movement at the American Board of Medical Specialists to get this specialty recognized. He helped craft the concept of mandatory recertification every seven years to alleviate the anxiety about the continuing competency of the family physician. He offered the services of the NBME to assure that the examinations produced by the ABFP were of high quality. He persuaded multiple specialty boards to nominate individuals to serve as test committee members.

In contrast to his accomplishment in the development of a generalist discipline was Hubbard’s leadership in the creation of the newly recognized subspecialties of the 70’s. I was recruited to work with the American Board of Internal Medicine (ABIM) to develop a set of new examinations for ten subspecialties in internal medicine. It was during these early experiences with Hubbard and the leaders of the ABIM that I began to understand John’s leadership style. Hubbard would take a position and with a strong but gentle manner, listen to counter positions and then craft out a final approach that was guided by a set of personal principles. John Hubbard was consistent, persistent and committed to excellence. The new subspecialty examinations in internal medicine and in pediatrics met the highest standards in test development.

A Consensual and Caring Approach to Enhancing Medical Education (1980-1990)

At the end of 1979, I was invited by Edward Stemmler, Dean at the University of Pennsylvania School of Medicine to be a candidate for associate dean for Academic Programs. Stemmler recognized that modern deans needed help in meeting the educational mission of the school. He felt that someone with competency in medical education should lead all aspects of the school’s educational program from admissions to curriculum. Luckily, I was chosen to take on this responsibility.

Working with Stemmler, we crafted two major curricular revisions and shared with the country our management structure for medical education. Stemmler’s leadership style is reflected in how we brought about change. He constantly reminded me of the need to bring about evolutionary change. One of his favorite comments was, “I can’t let you get the bit between your teeth or we’ll go over the edge; and if we do, no movement.” He promoted a caring approach to the educational process. He demonstrated by deed that kindness yielded great rewards. By the end of the 80’s Penn Med was rated as the third best medical school in the U.S.

He also had as an underlying philosophy the critical need for a real partnership amoung faculty, students and administration. He reminded senior leadership that lasting effective change required a buy-in by the constituencies that “we serve.” One outcome of this approach was the establishment of one of the first faculty group practices in America. This was done as a process owned by all involved parties, and not by dictate.

I vividly remember our students’ recognition of Stemmler when he stepped down from the deanship. There he stood surrounded by singing students smiling and crying together.

A Corporate Approach to Academic Medicine (1990)

In 1989, William Kelley came to the University of Pennsylvania as dean of the University of Pennsylvania School of Medicine, CEO of the University of Pennsylvania Medical Center and CEO of the University of Pennsylvania Health System.

One description that comes to mind in trying to describe Kelley’s style is that the CEO knows best. Once all the data are in the CEO decides what to do. It is well known that for-profit companies are managed on the basis of the bottom line and thus, decisions are made on the impact of one choice versus another on the bottom line. I believe, Kelley applied a variant of such a philosophy to medical education. Here are some examples of the way this approach functioned at Penn Med. If an affiliated hospital was likely to leave to join another health care alliance and a business association with that hospital was of questionable profitability, then the affiliation needed to be terminated and our students would not be allowed to take required clerkships at that institution. If attending physicians were not seeing enough patients, then there needed to be adjustments in the teaching programs to give them more time to generate their salaries. If the salaries of basic scientists were not being covered, then they needed to get more grants and our teaching program adjusted. From a business and survival point of view, this approach probably makes sense.

I watched Kelley change by force of leadership style the structure, mood and ambiance of Penn Med. I watched many of my friends fall victim to a corporate environment. Yet the University of Pennsylvania Health System made millions and millions of dollars. To many, Bill Kelley is a hero as building after building was constructed, practice after practice purchased and more and money put into new research and service programs. To many, Bill Kelley is Penn Med’s greatest Dean. The University of Pennsylania Health Care System is now considered by many to be the corporate model for academic medicine for the 21st century.

A Final Challenge

As I say good-bye to Philadelphia, I notice two things as I drive to my office at 42nd and Pine before my last days at Penn and my last days in Philadelphia. First, a young medical student in a hurry, intense, eyes to the ground seemingly unaware of his environment. Second, I see the dilapidated houses, the abandoned cars, the dirt, the broken windows, broken furniture waiting to be picked up, and a homeless person sitting on the curb. This is west Philadelphia, only blocks from the University of Pennsylvania Medical Center.

Fredric D. Burg, M.D., is the former Vice Dean for Education and Professor of Pediatrics at the University of Pennsylvania School of Medicine. He is currently Associate Dean for the University of Alabama School of Medicine/Huntsville Program.

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