Relationship University and Academic Hospital in Medical Education Between Charybdis and Scylla ? Ben Van Camp, MD, PhD.

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

Biomedical sciences

(Pre)Clinical sciences

Clinical practice

Specialisation Training : Clinical specialist ( n > 30 ) General practitionar Public Health Medical Research (PhD)

Undergraduate: 2-3 year

Graduate: 3-4 year

Postgraduate: 3-6 years

Continuous education: life long

Secundary school

Entrance prerequisites

continuum

A birds view on Medical Education

Basic biomedical sciences

General clinical training

Clinical specialist ( > 30 )General practitionar

Public health organisation

Medical sciences

Medical Research

Scientific Environment

Clinical EnvironmentTranslational medicine

Basic clinical skills

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

Brussels airportMedical campus

University main campus

The academic medical center: the Brussels (VUB) Experience

Faculty of Medicine

University Hospital

Erasmus CollegeNursing scool

Campus: 37 hectare

The academic medical center: the Brussels (VUB) Experience

- 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

  - 147.000 m2 buildings

  - 16.000 m² lab’s

  - 8 aula’s, library

  - 50 teachingrooms,

  - restaurant

- 6 master programmes

- doctoral School

Faculty of MedicineUniversity Hospital

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.

RectorBoard directors ChairmanVUB

Governance structure of UZBrussel

Medical council

UZBrusselBoard directorsChairman

CEO (MD, PhD)Management committee(CFO;HRM;IT;etc

Delegated power

UZResearch Council

Steering committee:Chairman,Dean,CEO

Committees: - financial - strategic - audit

VUB R&DResearch councilMed. School

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.

RectorBoard directors ChairmanVUB

Governance structure of Medical Education

UZBrusselBoard directorsChairman

Delegated power

Medical faculty

departements (5) divisions (30)researchgroups

Teaching programs

ResearchPrograms

MD program Biomedical Sciences programFarmacy program

MD/AcademicCorps (67)All MD’s (413)

Academiccorps

R&D

UZBr R&D

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 committeeNote: 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 )