Relationship University and Academic Hospital in Medical Education

1
Relationship University and Academic Hospital
in Medical Education

• Between Charybdis and Scylla ?
• Ben Van Camp, MD, PhD

2
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 gt 30 ) General practitionar Public Health
Medical Research (PhD)
Doctor
Postgraduate 3-6 years
Continuous education life long
3
A birds view on Medical Education

Scientific Environment
Basic biomedical sciences

Basic clinical skills
General clinical training
Medical sciences
Clinical specialist ( gt 30 ) General
practitionar Public health organisation
Medical Research
Translational medicine
Clinical Environment
4
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
  )

5
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

6
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

7
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 ?

8
The academic medical center the
Brussels ( VUB ) experience
Medical campus
Brussels airport
University main campus
9
The academic medical center the
Brussels (VUB) Experience
Campus 37 hectare
Erasmus College Nursing scool
Faculty of Medicine


University Hospital

10
The academic medical center the
Brussels (VUB) Experience

Faculty of Medicine
University Hospital

• - 147.000 m2 buildings
• - 16.000 m² labs
• - 8 aulas, 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

11
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
• - gt 70 fulltime MDs
• - gt 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

12
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
  (1970s) 100m²/UZ bed compared to
  80m²/non-U.b.

13
Governance structure of UZBrussel
UZBrussel Board directors Chairman
Rector Board directors Chairman VUB
Committees - financial - strategic - audit
Delegated power
VUB RD Research council Med. School
UZResearch Council
Steering committee Chairman,Dean,CEO
Medical council
CEO (MD, PhD) Management committee (CFOHRMIT
etc
Board directors VUB 5 delegates (rector,
chairVUB,Dean) UZB 5 delegates (MC) External 5
members
14
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 MDs with PhD appointed in UZBrussel have
  academic appointment at faculty (in principle no
  staff appointement without PhD)
• All MDs are appointed by UZBr but selected by
  joint committee (Fac/UZ)

15
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,rese
  arch, 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)
  gt 20.0 milj.

16
Governance structure of Medical Education
Rector Board directors Chairman VUB
UZBrussel Board directors Chairman
Delegated power
RD

MD/Academic Corps (67) All MDs (413)
Medical faculty
departements (5) divisions
(30) researchgroups
Research Programs

UZBr RD
Teaching programs
Academic corps
MD program
Biomedical Sciences program Farmacy program
17
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!!

18
Governance of Medical Education

• Educational programme is governed by faculty
• - curriculum committee
• - quality control on curriculum/courses/academic
  s/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)
• RD-Innovation programmes are linked to academic
  promotor
• - grant application and financial-legal matters
  aided by RD-VUB
• - RD-UZB aids clinical research in accordance
  with RD-VUB
• Policy for Integrated Centers of Excellence
  between clinical divisions and faculty research
  groups (ex. Diabetes, Oncology Center,
  Reproductive Medicine, etc.)

19
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

20
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)

21
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 )