Cover Story - October 2009
Tex Med. 2009;105(10):10-24.
By Ken Ortolon
On a hot August morning, 40 first-year medical students sat in a classroom listening to a lecture on innate immunity. On the desk in front of each sat a black laptop computer on which the students followed the professor's slide presentation as she discussed leukocytes and chemokines. A handful of faculty members sat in the back of the room, monitoring the proceedings.
The scene could have played out at virtually any medical school across the country. But this particular class took place at Texas' newest medical school, the Texas Tech University Health Sciences Center Paul L. Foster School of Medicine in El Paso.
The Foster School of Medicine opened its doors to its inaugural class in July and became the first medical school on the U.S.-Mexico border. Its opening culminated 30 years of dreaming and 10 years of hard work by the medical community and civic leaders in El Paso and Texas Tech System officials.
Founding dean Jose Manuel de la Rosa, MD, says the Aug. 1 "white coat" ceremony, during which members of the initial class received their first laboratory coats, was "the party we've all been waiting for for 10 years."
It's been a decade since then-Texas Tech Chancellor John T. Montford set the wheels in motion to convert Tech's regional campus in El Paso into a full four-year medical school.
"It's kind of a dream come true," Dr. de la Rosa said of the start of classes.
Members of the El Paso medical community and the students themselves also are excited to be part of what they see as a seminal event in border history.
"We're all very proud that this finally came to fruition after all the hard work by our community leaders, as well as the county medical society," said Luis H. Urrea II, MD, president of the El Paso County Medical Society and a member of the Texas Tech clinical faculty.
Medical student Nelly Estrada, a native El Pasoan who grew up just across the Rio Grande in Ciudad Juárez, is excited by the unique opportunities to be part of the very first class of medical students on the border.
"I knew it was going to be something big, and I wanted to be part of that, particularly because I grew up in this area and I wanted to make an impact in the community where I grew up," said Ms. Estrada, a 2009 recipient of a Texas Medical Association Minority Scholarship.
Ms. Estrada is just the type of student that the Foster School of Medicine is targeting - students who are likely to stay and practice medicine on the border after graduation.
"We believe if you recruit them from the border, you teach them on the border, you can keep them on the border," Dr. de la Rosa said. "That's our little mantra."
Admissions policies are not the only unique aspect of the Foster School of Medicine. The curriculum fully integrates the learning of basic sciences with clinical experiences that will show students how those sciences are applied.
"In its simplest form, this is the style of curriculum in which knowledge is gained in the format in which it will be used," said Brian W. Tobin, PhD, associate dean and founding chair of the Department of Medical Education.
Realizing the Dream
The Foster School of Medicine opened July 13 with 40 students in its first-year class and plans to admit 60 students in 2010 and 80 in 2011. Dr. de la Rosa says the school can handle 100 students, and he hopes to expand to that number at some future date.
Dr. de la Rosa says people in El Paso have been talking about a medical school for more than 30 years, ever since the Texas Tech University Health Sciences Center opened a regional campus there to train third- and fourth-year students, as well as residents, in the 1970s.
Dr. Urrea says local physicians also were early proponents of a medical school, led in large part by the late Wm. Gordon McGee, MD, a former TMA president.
But it was not until 1999 that the dream started to take shape when Chancellor Montford laid out his vision for the new school to the Tech Board of Regents. In 2001, Texas Tech received $1.5 million in state funds for planning for the new school. And, in 2003, Texas lawmakers finally authorized the Texas Tech System to proceed with its plans to issue bonds to finance construction of new classroom and research buildings. In 2005, lawmakers also approved nearly $7 million in funding to cover the bond debt service, infrastructure support, faculty salaries, maintenance and operation, and library resources.
The school is located on roughly 12 acres of donated land adjacent to the existing regional campus and close to University Medical Center, formerly Thomason Hospital, near downtown El Paso. Ground was broken on a 93,000-square-foot medical science building in December 2003. That building, completed in 2005, currently houses laboratories and other facilities conducting research on cancer, diabetes and obesity, environmental health, and infectious diseases.
Construction on the medical classroom building began in December 2005 and finished in 2007. The 125,000-square-foot building includes classrooms, a library, small group rooms, a clinical skills area, faculty and administrative areas, basic sciences labs, a gross anatomy lab, a student services area, and food services.
The school is named for the president and chief executive officer of Western Refining Inc., who Dr. de la Rosa says gave both a generous and timely donation in 2007. Mr. Foster's gift of $50 million for the medical school was the largest donation ever received by the Tech System.
On the Border
From the beginning, the school's goal has been to train physicians who likely will stay and practice on the border, whether that is El Paso, Del Rio, Brownsville, or elsewhere.
About a quarter of the initial class grew up on the border, including Thomas Tullius Jr., an El Paso native who graduated from Princeton University in 2007 with a degree in chemical engineering. He worked in the pharmaceutical industry in Houston for a while but took a lower paying job to be able to return to El Paso, where his family still lives.
Mr. Tullius was excited to learn that El Paso would have a medical school, and it was his first choice when he decided to pursue medicine as a career.
Cynthia Garza, JD, is another border-area resident in the initial class. She is starting a second career after graduating from law school and working as a federal public defender in San Antonio. More recently, she has worn many hats in helping her husband run his cardiology practice in Del Rio, including being his office manager, medical assistant, and billing clerk. Ms. Garza says she decided to pursue medicine as a career after working as a public defender on a case involving Munchausen by proxy syndrome. Her role was dealing with the medical aspects of the case.
"At that moment I realized, 'My God, I have a calling, not just a profession,'" she said.
Manuel Schydlower, MD, associate dean for admissions and professor of pediatrics, says nontraditional students such as Ms. Garza are part of the "holistic approach" to admissions that the Foster School of Medicine has adopted.
"We do place a high value on academic achievement, but we're also interested in the personal qualities of the applicant, the applicant's motivation, altruism. We're interested in the applicant's communication skills," Dr. Schydlower said. "In other words, we look at both cognitive and noncognitive factors to appraise an applicant."
Dr. Schydlower says school administrators were pleased that they had 2,500 applicants for the 40 slots in the first-year class, far higher than the average applicant-to-position ratio for medical schools across the nation. According to the Association of American Medical Colleges, there were 13 applicants for every medical school position in 2007-08. That compares to 62.5 applicants for every slot for the Foster School of Medicine's first-year class.
Of those applicants, Tech officials interviewed nearly 400 before choosing the inaugural class.
"What impressed candidates was what we had to offer," Dr. Schydlower said. "We had candidates who were accepted to other schools but turned down those other schools to come here because of the appeal of what we have to offer as a new school."
Integrating the Curriculum
To start, the Foster School of Medicine benefits from being a new school in that all of its facilities and equipment are state-of-the-art. This ranges from the robotic mannequins in the clinical simulation labs that can not only mimic illnesses and conditions but also talk back to the students, to the high-tech computers in the anatomy lab that can display full CT scans of cadavers the students are dissecting.
But the real draw for students likely is the curriculum, which several faculty members described as a fully integrated curriculum that gets students involved in the clinical side of medicine early. That is opposed to traditional medical school curricula in which the first two years of study are nearly confined to classroom studies of basic sciences.
"It's a curriculum that teaches the basic sciences with relevance to patient care utilizing clinical presentations," Dr. Schydlower said. "That was very appealing to the applicants and to the candidates we looked at."
David J. Steele, PhD, senior associate dean for medical education and director of the Office of Curriculum, Evaluation, and Accreditation, says the school could adopt innovative approaches to its curriculum because it doesn't have the "long, ongoing tradition" that many medical schools have.
"Curriculum change is often likened to trying to move a graveyard," Dr. Steele said.
The integrated curriculum approach was based on an educational model developed at the University of Calgary, which Dr. Steele says has data showing that basing instruction on clinical presentation enhances basic science knowledge retention. While the Foster School of Medicine incorporates some significant changes from the Calgary model, including more emphasis on basic science, Dr. Steele and other officials are confident they will achieve similar results.
"We're trying to provide the students with an introduction to the clinical reasoning and thought processes that an experienced clinician would use in thinking about a patient who presents with that particular clinical presentation," he said. "And, at the same time, we're also introducing the students to the basic science concepts and content that the student would need to know in order to best understand that presentation and to have a framework for thinking about a patient who presents with that particular problem. The rationale for that is when you present information in the context of its application, it's more memorable, the student's retention is much better, and the ability to transfer that information is a lot better."
The curriculum for the first two years is designed around four required courses: the scientific principles of medicine; a medical skills course; a master's colloquium that deals with professionalism, medical ethics, and other issues; and a course called society, community, and individual. The latter two courses are unique to the Foster School of Medicine and are not part of the Calgary model, says Dr. Steele.
Dr. Steele, who also previously helped develop the curriculum for Florida State University College of Medicine, which gained full accreditation in 2005, says the course with the most "contact hours" with the students is the scientific principles of medicine. That course involves 120 different clinical presentations such as chest pain, sore throat, and headache. The presentations are grouped around organ systems that are most pertinent to the presentation.
"In other medical schools, students will have courses in anatomy and courses in physiology, biochemistry, and the various 'ologies' that go into being a doctor," Dr. Steele said. "Those are really heavily front-end-loaded during the first and second years. And when the student makes the transition into the third and fourth years, the clinically intensive years when they're taking their clerkships in medicine, surgery, or pediatrics and they're starting to take care of patients, then the students have to go back and think about what of the anatomy that they've learned is relevant, what of the physiology is relevant, what concepts of biochemistry are relevant. What we're trying to do is to provide that framework right from the beginning."
Mr. Tullius says the emphasis on early clinical experiences was very attractive to him in choosing a medical school.
"I've heard other people say they forget the reason why they went to medical school the first two years," he said. "They forget that why they wanted to go [to medical school] was for the patients and the people, because all they're doing is studying."
Ms. Estrada says integrating clinical experience with the basic science education is motivating because students can see immediately what they will be able to do with the knowledge they are acquiring.
"It will help us relate what we're learning to something real out there, help us see what we learn applied," she said.
Dr. Steele says the medical skills course is aligned with the scientific principles of medicine. For example, when students learn about cardiovascular and respiratory systems in the scientific principles course, they also will learn how to take a focused history from a patient presenting with chest discomfort in the medical skills course.
Another innovative element of the curriculum is the society, community, and individual course, which focuses heavily on the basics of public and community health, as well as exposing the students to community and cultural experiences in El Paso.
In their first month on campus, students were assigned to community clinics across El Paso where they experience how care is delivered firsthand.
Mr. Tullius says one of his first experiences was following patients at a community clinic, from signing in at the front desk to sitting in the waiting room to finally seeing a physician.
Ana Arroyave, MD, assistant professor of family and community medicine and director of the society, community, and individual course, says the point of such early clinical experiences is to put the students in the "patients' shoes." This allows them to understand how long patients have to wait to be seen, what questions they are asked, and which clinic staff they interact with and what their roles are.
"After this experience, we have them reflect on the culture of the practice, what it was like to shadow a patient," she said.
Dr. Arroyave also says students are paired with "mentor families" who routinely get their medical care at those community clinics.
The students visit these mentor families in their homes to understand life and family dynamics on the border, how family interaction affects views on health care, and barriers to getting access to care.
"The ultimate goal is that they can have the perspective of community health and public health, that they can see a family's perspective on health and illness," said Dr. Arroyave. "It's basically exposing them to something they don't experience in the classroom."
Ms. Garza says visiting with families not only about medical issues but also about whatever social issues they're experiencing makes students better doctors. "It will make them more compassionate doctors; it's going to make then kinder people."
School officials didn't stop there in steeping their students in the local culture. Even before formal science classes began, they put the students through a three-week Spanish-language immersion course. Ms. Garza knows of no other medical school in the country that has a Spanish-language component as a required part of the curriculum.
Breaking Down the Silos
Dr. Tobin says the Foster School of Medicine also veered away from the traditional medical school structure in a couple of other significant ways. First, where traditional schools have separate departments of physiology, biochemistry, microbiology, and others, the El Paso school created a single Department of Medical Education that includes all of those disciplines.
"The leaders took very seriously the need to blend that all together into one department," Dr. Tobin said. "Because everybody is in the same department, we've gotten rid of all the silos. Because everybody is in the same department, we can build the program collaboratively as a team."
The other difference is the creation of four "colleges" within the medical school. Students are assigned to each college, much as grade school students are assigned a homeroom. Two masters - one MD clinician master and one PhD basic science master - lead each college.
"These college masters will have a four-year continuing relationship with the students assigned to their colleges," he said. "The masters are also going to be very much involved in student well-being, helping to monitor student progress, and, if a student is having difficulty, helping him or her identify the right resources for dealing with that."
Dr. de la Rosa says launching the new medical school has been rewarding for him, as well as an economic boon to the entire El Paso community.
"To see it actually, literally coming out of the ground and coming together has been a real honor and a privilege," he said. "It really is humbling to watch it."
He says University of Texas at El Paso researchers estimate the school could have a $10 billion impact on the El Paso economy. This includes construction jobs created by the school; spin-off industries from research conducted on campus; long-term, high-paying jobs on the faculty and research staff; and the increases in residency programs that are planned to provide graduating students with opportunities to continue their training in El Paso.
That, he says, is vital for "one of the most depressed areas in the country. The medical school becomes an economic driver for the community."
But the end goal, Dr. de la Rosa says, is to address the demand for more physicians in El Paso and the entire border region.
"We're beginning to address El Paso's need for specialists and subspecialists, as well as the border's need for primary care physicians," Dr. de la Rosa said. "So we're trying to fill two niches at once."
They've already created a new radiology residency program and are looking to create residency programs in sports medicine, gastroenterology, renal medicine, cardiology, and anesthesia within the next few years. They also want to expand existing programs in family medicine, internal medicine, and pediatrics to fill the gaps in the current supply of primary care doctors on the border.
Another niche the Foster School of Medicine hopes to fill is in research into illnesses prevalent on the border. Dr. de la Rosa says the research programs now under way are very specific to El Paso and the border region. "Being located on the border, we need to look very closely at infectious diseases; we need to look very closely at the incidence of diabetes and obesity in Hispanics; we need to look at Hispanic breast diseases."
Charles C. Miller III, PhD, professor and chair of the Department of Biomedical Sciences and associate dean for research, says the school has four centers of excellence in areas of special interest to the border. Those include cancer, especially hormone-related cancers such as breast and ovarian cancer; diabetes and obesity, which he says are "particularly troublesome" in the Hispanic population; infectious diseases; and neuroscience.
"We're interested in traumatic neurological injury because Fort Bliss is here and a lot of soldiers coming back from Iraq come through here," Dr. Miller said. "Body armor is getting better now, so the injuries that used to kill people are now survivable. But they leave more devastating injuries, neurological injuries."
Finally, Dr. de la Rosa says the school hopes to be a driver to "grow services" in El Paso. It is building a children's hospital in collaboration with University Medical Center.
What will be the school's ultimate impact on El Paso and the border?
"Hopefully, we will have built a conduit for physicians to come from the border, be trained on the border, be able to stay on the border, and be able to deliver health care on that border," Dr. de la Rosa said. "And that's what it's all about. It's all about the patient."
New Medical School for South Texas in Pipeline
While El Pasoans celebrate the opening of the Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, at least one other new medical school appears to be in the pipeline for Texas.
The Texas Legislature this year gave The University of Texas System authority to explore the possibility of converting the UT System's Regional Academic Health Center (RAHC) in the Lower Rio Grande Valley into a full four-year medical school.
The legislation, sponsored by Sen. Eddie Lucio (D-Brownsville), authorizes the UT System to establish a health science center with a four-year medical school in the Rio Grande Valley, but sets 2015 as the earliest date that the system could ask the legislature for funding for that institution.
Medical educators disagree on whether Texas needs more new medical schools, but there is little disagreement that the state needs to train more physicians.
"There are a lot of different factors that play into the question of whether we need more medical schools," said R. Michael Ragain, MD, chair of Texas Medical Association's Council on Medical Education. "It's not a yes or no answer. On the yes side, I think it's pretty clear that we need to grow the number of physicians in Texas and the United States. The predictions are that we're going to be short on physicians, and many of the medical schools in Texas have increased their class size in response to that."
The Association of American Medical Colleges estimates that the United States needs to increase medical school enrollment by 30 percent by 2015 to meet the growing demand for physicians. TMA supports both expansion of existing programs and development of new medical schools to meet this demand.
Jose Manuel de la Rosa, MD, founding dean of the Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, thinks the legislature was right on target to authorize a South Texas medical school.
"Our models for physician distribution and physician production back in the late '70s and early '80s were way off," he said. "We have an impending physician shortage crisis."
However, some medical educators say expanding existing schools may be a better approach.
"It's probably cheaper to increase the existing medical schools than it is to develop new medical schools in terms of adding physicians to the workforce," Dr. Ragain said. "There are economies of scale that help you do that in a more cost-effective way."
Nancy W. Dickey, MD, president of the Texas A&M University Health Science Center and vice chancellor of health affairs for the Texas A&M System, says whichever approach is pursued is going to require more dollars from the legislature.
"The current level of funding [for existing medical schools] is below the cost of educating medical students," Dr. Dickey said. "It does not adequately support infrastructure. It does not adequately support the capacity for recruitment and growth within the medical schools.
"So if you're going to consider more medical schools or, for that matter, even more students in existing schools, we need to have a commitment from the state legislature for more dollars to go into the pot. Otherwise, more medical schools simply translates to less money to the existing schools with an ever-growing expectation of the quality of their graduates."
Kenneth I. Shine, MD, executive vice chancellor for health affairs for the UT System, says officials have not decided to convert the Rio Grande Valley RAHC into a full four-year medical school. However, the system, through the UT Health Science Center at San Antonio, is increasing educational opportunities at the RAHC.
UTHSC San Antonio has plans to increase its class size and have some students complete their third and fourth years of medical school at the RAHC in Harlingen, after completing the first two years of medical school in San Antonio, Dr. Shine says.
"We're also exploring with some of the hospitals in the area the possibility of expanding medical residency programs," he said. "That is, in fact, a critical part of expanding it. People tend to practice where they do their residency, so we'd like to have opportunities for students who do their third and fourth years in South Texas at Harlingen to be able to get residencies there."
Those changes could eventually lead to a full four-year medical school in the Rio Grande Valley, Dr. Shine says.
"We are committed to expanding medical education and research at the Regional Academic Health Center, and, over a period of time, that could evolve in the direction that's consistent with what the legislature has identified," he said. "That's all subject to critical issues with regard to funding, and I think that the [UT System Board of] regents will be following the developments there very closely."
While the UT System has authority to develop a Rio Grande Valley medical school, discussions continue about other potential new medical schools. The UT System has talked about adding a medical school in Austin, although those discussions have been of an on-again, off-again nature.
Dr. Shine says any plans to have a medical school in Austin are on hold, given the economic circumstances and the amount of resources required "if we were going to think about such a thing seriously." The UT System is looking at expanding research and residency programs in Austin, and UT Medical Branch at Galveston plans to increase the number of medical students trained in Austin.
The University of North Texas Health Science Center recently proposed creating an allopathic medical school to complement its osteopathic school, but that proposal was met with considerable opposition.
While the debate over the need for new medical schools likely will continue, several existing schools are expanding their class sizes. A&M plans to expand from 150 to 200 students per class, split between its campuses in Temple and Bryan-College Station.
Texas Tech's Foster School of Medicine plans to expand from 40 students in its initial class this year to 80 students by 2011. In addition, Tech's Lubbock campus recently added third- and fourth-year students to its regional campus in Odessa. Those students would have trained at the former regional campus in El Paso.
Dr. Dickey says medical educators and the legislature also must be mindful of the need for new graduate medical education (GME) slots to go along with the increased class sizes.
"We certainly need to have a focus on increasing GME," she said. "That increase cannot come at the expense of supporting undergraduate medical education or medical schools. It has to be perceived as an additional commitment."
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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