Relationship University and Academic Hospital in Medical Education Between Charybdis and Scylla ? Ben Van Camp, MD, PhD
A birds view on the general structure of Medical Education in Europe Secundary school Entrance prerequisites Master Bachelor Biomedical sciences Undergraduate: 2-3 year continuum (Pre)Clinical sciences Clinical practice Graduate: 3-4 year Specialisation Training : Clinical specialist ( n > 30 ) General practitionar Public Health Medical Research (PhD) Doctor Postgraduate: 3-6 years Continuous education: life long
A birds view on Medical Education Scientific Environment Basic biomedical sciences Basic clinical skills General clinical training Medical sciences Clinical specialist ( > 30 ) General practitionar Public health organisation Medical Research Translational medicine Clinical Environment
The Flexner Report ( Carnegie Foundation 1910 ):Medical Education in the United States and Canada Revue of medical education offered at the beginning of 20th century in US and Canada. Taking into account the emerging scientific knowledge towards patientcare as was pioneered at Johns Hopkins Guidelines to best practice in medical education • Physical link of medical school with a comprehensive hospital under university auspices • Provision of specific hospital wards for teaching purposes • Staffing of medical school by regular university appointement ( generally accepted in US and EU today ) • No private practice but full time university salaries ( problematic fulfillment )
Scientific environment in Medical education University Faculty of medicine (= medical school ) core departments with associated research facilities: - biomedical sciences - pre-clinical sciences - clinical sciences Other faculties or associated departements - basic sciences ( fac. Sciences ) - public health ( fac. Humanities ) - bio-engineering ( fac. of Engineering ) - medical biotechnology and molecular biology ( fac. of Science ) - medical ethics, law, economics, sociology ( fac. Humanities ) - medical communication and psychology ( fac. Humanities ) - medical IT, etc. ( fac. Engineering ) University Hospital Clinical and translational research in medical disciplines
Clinical Environment in Medical Education Skills training center (faculty medicine) Comprehensive teaching (= academic) Hospital: - specific teaching wards (“bedside teaching”) - complete spectrum of specialities (postgraduate) - academic- clinical teaching staff - evidence based medicine (“rounds”) Affiliated (non academic) hospitals: - pre-specialist practice - specialist training (“maitre de stage”) General Practice training - academic – clinical teaching staff Teaching Staff under supervision of Medical School
Medical Education at a crossroad How to integrate scientific and clinical environment ? Who is paying for Medical Education: social security, ministry of health, ministry of education ? Will Odysseus pass Charybdis and Scylla undamaged ?
The academic medical center : the Brussels ( VUB ) experience Medical campus Brussels airport University main campus
The academic medical center: the Brussels (VUB) Experience Campus: 37 hectare Erasmus College Nursing scool Faculty of Medicine University Hospital
The academic medical center: the Brussels (VUB) Experience University Hospital Faculty of Medicine • - 147.000 m2 buildings • - 16.000 m² lab’s • - 8 aula’s, library • - 50 teachingrooms, • - restaurant • - 6 master programmes • - doctoral School - beds: 729 (occupancy 76 %) - personel: 3003 (413 MD – 84% FT) - 26.252 hospitalisations (av. 7d) - 18.125 day hospitalisations - 488.414 ambulant patients - 55.489 emergency patients
Academic tasks of UZBrussel • According to Belgian law a University with a full program of Medical Education can have a University Hospital (7), whether or not in a separate legal entity • Legal accreditation of “ University hospital “ is linked to specific function in (para)medical education, postgraduate training, continuous ecucation, applied clinical and translational research, additional criteria: - 1MD/3 beds - > 70% fulltime MD’s - > 70% MD employed by Hospital - all clinical disciplines accredited for postgraduate training • A specific number of “University Beds” are recognised of which most are located in the University Hospital, few in associated hospitals
Financing of academic task of UZBrussel UZBrussel global income: 263.000.000 EUR (2007) Income for academic task: • B7 parameter ( health ministry ): 5,4 % of G.I. B7 parameter: Federal budget is allocated to 7 University Hospitals weighted on the basis of - 25% for n. scientific publications - 15% for n. postgrad.stud./”maître de stage” - 60% for global budget • university ( academic personnel (67/413 MD) allocation: 0,9 % of G.I. • research, patents, clinical studies’ income: 2,5 % of G.I. • sponsoring: 0,5 % of G.I. total 9,3 % Estimated real academic cost (Antares Study): 25,0 % Note: Cost of UZBrussel buildings ( taking into account the academic function ) separate budget (1970’s); 100m²/UZ bed compared to 80m²/non-U.b.
Governance structure of UZBrussel UZBrussel Board directors Chairman Rector Board directors Chairman VUB Committees: - financial - strategic - audit Delegated power VUB R&D Research council Med. School UZResearch Council Steering committee: Chairman,Dean,CEO Medical council CEO (MD, PhD) Management committee (CFO;HRM;IT;etc Board directors: VUB: 5 delegates (rector, chairVUB,Dean) UZB: 5 delegates (MC) External: 5 members
Faculty of Medicine ( Medical School) • 8 faculties in comprehensive university VUB • Faculty of medicine: 5 departements: - basic clinical sciences (5 divisions) - pre-clinical sciences (5) - clinical sciences (7) (linked to UZdepartements) - Farmacy departement (4) - Primary Health and Social Medical Sciences (6) - ( Dentistry ) • Ba-Ma-Dr structure in educational programmes (MD, Farmacy, BMS, Gerontology, Med. Social Sc., Mr. Nursing) • Research groups or centers (cluster of research groups) are thematically organised around directors • All MD’s with PhD appointed in UZBrussel have academic appointment at faculty (in principle no staff appointement without PhD) • All MD’s are appointed by UZBr but selected by joint committee (Fac/UZ)
Financing of faculty of Medicine VUB total income: 200.600.000 EUR ( 2007) - regular budget (min.education): 83.3 milj. (output based system) - infrastructure: 3.4 milj. - social student facilities: 2.0 milj. - Special Research Fond (min. Science): 11.9 milj. - External Research programmes: 32.8 milj. - international organisations 7.7 milj - patrimonium and (diverse): 59.5 milj Centralised Academic and A/T services for education, infrastructure, student-facilities,research, innovation, etc. Faculty budget (2007): • Academic (115 FTE) and A/T personnel: 12.5 milj. ( UZBr based: 3.0 milj !!!! ) - Educational working credit: 0.540 milj. - Research money ( competition based): > 20.0 milj.
Governance structure of Medical Education Rector Board directors Chairman VUB UZBrussel Board directors Chairman Delegated power R&D MD/Academic Corps (67) All MD’s (413) Medical faculty departements (5) divisions (30) researchgroups Research Programs UZBr R&D Teaching programs Academic corps MD program Biomedical Sciences program Farmacy program
Conclusion Integration between hospital and faculty is paramount for MD Education but hampered by differences in: - governance structure - income sources - mission - salaries of MD versus AP Integration “top-down” versus “bottom up” “If you have seen one medical center .... you have seen that one medical center!!”
Governance of Medical Education • Educational programme is governed by faculty: - curriculum committee - quality control on curriculum/courses/academics/teaching facilities - appointment of Academic Personel (even MD in UZB) - MD appointment in UZBrussel is approoved by joint faculty/medical council committee Note: 67 joint appointments MD-AP (26 % of total faculty AP) • R&D-Innovation programmes are linked to academic promotor: - grant application and financial-legal matters aided by R&D-VUB - R&D-UZB aids clinical research in accordance with R&D-VUB • Policy for Integrated Centers of Excellence between clinical divisions and faculty research groups (ex. Diabetes, Oncology Center, Reproductive Medicine, etc.)
Medical Education at a crossroad • Medical education integrates evolving biomedical scientific knowledge and clinical handling of diseases in a public health setting. • Endterms of academic medical education includes scientific thinking and aptitude to enter medical profession • The quality of Medical Education is dependent on an integrated setting of academic rigour and clinical excellence. • The cost for an excellent Medical Education is high
Academic Medical Center Brussels • 4 entities: - university medical school (VUB) - UZBrussel (legal entity VUB, but delegated power) - Erasmus Health college (associated to VUB) - Sportscenter (PP enterprise) • First 3 are implicated in teaching programmes and (basic, applied or translational) research projects within the broad spectrum of health. • All have a different - governance structure - financing system (direct cost driven, different financing bodies) - output guided budgets - specific task, with centrifugal goals • Research driven financing (covering direct cost) is increasing the indirect costs with a need for building expansion (not adequately covered by financing bodies)
Scientific environment in Medical education • University • Faculty of medicine (= medical school ) • core departments with associated research facilities: • - biomedical sciences: biophysics, biochemistry, anatomy, • histology, biostatistics, fysiology, immunology, farmacology, microbiology, etc. • - pre-clinical sciences: patho-fysiology and biochemistry, farmacotherapy, medical genetics,organ-linked pathology,etc. • - clinical sciences: introduction to clinical specialities, disease management, medical specialities, translational and clinical research • associated departements ( intra-medical school or other faculties ) • - basic sciences ( fac. Sciences ) • - public health ( fac. Humanities ) • - bio-engineering ( fac. of Engineering ) • - medical biotechnology and molecular biology ( fac. of Science ) • - medical ethics, law, economics, sociology ( fac. Humanities ) • - medical communication and psychology ( fac. Humanities ) • - medical IT, etc. ( fac. Engineering )