February 15, 2013

 

 ‘Philosophical differences of opinion’

​Plenty of issues brought up at USDE meeting; few answers

  
Conflicting views within the veterinary profession related to workforce issues and student education have taken center stage recently.
 
The AVMA Council on Education, in pursuit of recognition by the Department of Education, appeared before a USDE advisory panel, the National Advisory Committee on Institutional Quality and Integrity, Dec. 12, 2012, in Washington, D.C. (see article).
 
Critics of the council saw this as an opportunity to voice their opinions in a public forum.
 
NACIQI, which makes recommendations to the USDE on whether to recognize accreditors, received 13 letters recommending against the council’s continued recognition, and a few of the authors made remarks at the meeting.

Though the meeting did not settle any disputes, it did spur action for potential changes to the COE. It also provided a clearer picture on the role of accreditation and what it is—and is not—responsible for.  

Up to standards

Drs. Paul D. Pion, president of the Veterinary Information Network, and Robert R. Marshak, dean emeritus of the University of Pennsylvania School of Veterinary Medicine, were among those who sent letters to the DOE and spoke against the council at the meeting. Both are longtime, vocal critics of the COE, particularly after its accreditation of the veterinary schools at the Western University of Health Sciences, Pomona, Calif., and the National Autonomous University of Mexico, Mexico City, in 2010, as well as those at Ross University, Basseterre, St. Kitts, and St. George’s University, True Blue, Grenada, in 2011.

St. George’s University School of Veterinary Medicine received AVMA Council on Education accreditation in fall 2011. Subsequently, the veterinary school saw the number of applications nearly double from its fall 2011 semester (281) to its fall 2013 semester (587). St. George’s starts two new classes each year, in the fall and spring. Its total enrollment as of mid-January was 509 students.
Photo by Malinda Larkin
 
Also making comments critical of the COE were Dr. William J. Kay, a former COE member; his wife, Dr. Nancy Brown; Dr. James F. Wilson, co-founder of VetPartners, a veterinary management consulting firm; and Dr. Frank Walker, a former COE member.

Representing the council were its chair, Dr. Sheila W. Allen, dean of the University of Georgia College of Veterinary Medicine, and Dr. David E. Granstrom, director of the AVMA Education and Research Division. Those who spoke in favor of the council were Dr. Deborah Kochevar, former COE chair and dean of the Tufts University Cummings School of Veterinary Medicine; Dr. Andrew Maccabe, executive director of the Association of American Veterinary Medical Colleges; Dr. John Pascoe, executive associate dean at the University of California-Davis and a COE member; and Mark Cushing, a lawyer and veterinary education consultant. Dr. Kochevar also read a statement at the meeting, signed by 50 individuals who said they believe the COE offers a “proven process for educational evaluation.” (The signatories were current administrators representing programs at 22 of the 28 U.S. veterinary colleges, among them: two provosts, 18 current deans, three emeritus deans, 16 associate deans, one emeritus associate dean, and 10 department chairs or hospital/diagnostic laboratory directors.)

Generally, it is uncommon for accreditors going before the federal panel to have third-party commenters, said Judith Eaton, president of the Council for Higher Education Accreditation, who has watched the recognition process for many years.
“Oftentimes, when it does happen, it’s tied to philosophical differences of opinion in a professional field,” she said.
In the COE’s case, this was no exception.

Dr. Marshak, in his comments before NACIQI and in published editorials, criticized the way the COE has applied its standards. In one commentary, he wrote: “I believe that the COE’s recent interpretation of the standards has been excessively lenient and that such a permissive trend, if continued, threatens the future quality of veterinary education.” (See JAVMA, Nov. 1, 2011.)

At the meeting, he singled out Western as an example of an institution where he doubts students are getting the training worthy of an accredited veterinary program. Among his concerns is the fact that students receive their clinical exposure at a large number of off-site facilities that can be very different from one another. He contends that, given that Western contracts with more than 700 private practices, it’s impossible for academicians to monitor what students are learning, if anything.

Dr. Maccabe, in an interview with JAVMA, said while that may seem like a large number, there are, in fact, a much smaller number of core clinical sites—slightly more than 50—that constitute the veterinary college’s distributive teaching hospital.

The COE, which had a site visit at the campus late this past year, visited each of those sites for evaluation, Dr. Granstrom told JAVMA.

Western faculty also visit each core clinical site during every two- or four-week rotation for the third- and fourth-year students.

Students are taught and evaluated by both Western faculty and preceptors. Plus, they all rotate through the on-campus small animal clinical facility during their first two years. They may also select on-campus elective rotations during their last two years.

“The other thing about distributive models is nearly all veterinary colleges use some form of the distributed or off-campus clinical instruction model and have for many years, in the form of externships. It’s nothing new, just that Western has taken it to another level,” Dr. Maccabe said. He added that many medical schools have fully distributive models and have had them for a long time.

Dr. Granstrom said Dr. Marshak’s concerns about the relaxing of standards are unwarranted. Importantly, accredited colleges are not required to use identical methods to meet the standards, and the standards are designed to have enough flexibility to allow innovation and creativity, he said.

USDE staff seemed to agree, saying in their report: “In the absence of supporting information, department staff could not make an assessment of the agency’s alleged misapplication of standards in the case of the for-profit schools in question.” (Western and St. George’s are actually private, nonprofit institutions; only Ross is for-profit.)
 

Money woes

Three of the four veterinary schools accredited by the COE in the past three years are located in the Caribbean or Mexico. This has stirred its own debate among veterinarians on whether the COE should continue to recognize non-U.S. schools and how their graduates affect the U.S. workforce.

Dr. Wilson said by accrediting these schools, the COE has created adverse effects on the profession because of the higher-than-average debt the graduates from the Caribbean incur. Through his experience teaching at one or both schools over the past decade, he estimates that most of the students attending Ross and St. George’s now graduate with $250,000 to $320,000 of federally funded educational debt, compared with the mean educational debt of $151,672 incurred by U.S. students graduating with debt in 2012.

(According to St. George’s figures, the average loan debt for its students during the 2011-2012 year was $151,928.)

Dr. Wilson, who teaches veterinary students at most U.S. and Caribbean veterinary schools about personal finance, also predicts that continuing to expand the number of U.S. graduates of accredited foreign programs will feed an already oversupplied market of small animal veterinarians in the United States.

According to Dr. Wilson’s prepared remarks, “What has been most disconcerting is that until recently neither the AVMA, the COE, nor the AAVMC have sought to determine an accurate head count of the number of students in veterinary school outside of the U.S.A. nor have they studied the impact this rapidly growing number will have on the fiscal health of the nation’s privately owned veterinary practices.”

The AVMA did create the Task Force on Foreign Veterinary School Accreditation in August 2011 to evaluate, among other things, the impact of foreign veterinary school accreditation on the U.S. veterinary profession, and the quality of standards for the U.S. veterinary profession, and the impact of not requiring graduates of accredited foreign schools to be certified by the AVMA Educational Commission for Foreign Veterinary Graduates or by the American Association of Veterinary State Boards’ Program for the Assessment of Veterinary Education Equivalence. The task force report should be ready for review at the April AVMA Executive Board meeting. 

In addition, the AVMA has funded a comprehensive workforce study to determine whether an oversupply actually exists, and, if so, which sectors of the profession are affected and to what extent. The results of that study should be available this spring.

The AVMA doesn’t plan to include St. George’s and Ross in its Annual Senior Survey. Allison J. Shepherd, AVMA senior research projects manager, said the problem is that doing so causes issues with trended data, and the institutions can’t be reported individually.

As for the AAVMC, Dr. Maccabe said the association is just beginning to collect data on UNAM, Ross, and St. George’s, now that they are full AAVMC members. Recent AAVMC data show that, among all accredited overseas veterinary colleges, the Class of 2012 numbered 419 U.S. citizens. For the Class of 2015, that figure was 554. Comparatively, the total number of fourth-year graduates from U.S. colleges went from 2,201 in 2006 to 2,725 in 2012. The national Class of 2015 at U.S. colleges is right at 2,938.

Regardless, the main impact accreditation of these programs has had, Dr. Granstrom said, is that “it does provide oversight and ensures continuous improvement for two schools (Ross and St. George’s) that have been educating American citizens for years, thus boosting the quality of veterinary medicine in the U.S., not diminishing it, as some have stated.”

Notably with UNAM, only two graduates have taken the North American Veterinary Licensing Examination since the veterinary school was accredited. 

Making sure standards are met

Despite the impassioned testimony of those who warned that COE actions fuel a looming veterinary surplus, back-breaking student indebtedness, and unchecked tuition hikes, NACIQI members told critics at the meeting that it’s not within the agency’s purview to consider market demands or an accreditation body’s endeavors in foreign countries. Moreover, it is not the COE’s responsibility to act as a workforce gatekeeper, according to the advisory panel.

Increased enrollment can compromise compliance with several standards. This is the only reason the COE requires veterinary colleges to report enrollment annually. If they intend to increase enrollment by 10 percent or more, they must notify the COE immediately.

“Along with that, they are required to provide documentation they have changed resources accordingly. So as long as the institution can document the increase in enrollment has been accommodated for with resources applied, it’s not up to the COE to say if it can increase or decrease. Our responsibility is to make sure the quality of the educational experience is not diminished,” Dr. Allen said.

Accreditation, after all, is about setting standards, collecting data, and determining whether an institution meets standards, Dr. Kochevar said.

Criticism is healthy, Dr. Kochevar noted, and the COE may have areas to improve on, but the approach taken by critics at the meeting was not constructive.

“I think the council does an excellent job, and I think the key to getting (to an even better place) is to work collaboratively rather than taking the approach for the (USDE) not to credential the COE. That’s a destructive approach,” she said. “I wish those with relevant issues would come forward and talk about it in a data-driven, rational way.” 

Two are better than one?

Concerns about the accreditation process were also brought up at the meeting, and as a result, changes may be on the way.
 
According to the DOE staff report: “The comments express concern regarding the agency’s independence from the association and thereby its ability to reach impartial accrediting decisions. The comments also allege that the agency represents a commercial bias that favors corporate veterinary practice. Commenters assert that such a focus has compromised the rigor of veterinary education and has deteriorated the quality of the veterinary profession’s research and scientific contributions.”
 
Dr. Allen responded at the meeting that, having been on the COE for six years, she can say with conviction that the AVMA having influence over the COE is not true.
 
And as for a commercial bias, “There are practitioners on the council, and I think that is appropriate, since private practitioners make up the vast majority of our profession. I think they should have a voice in how veterinary education is moving. I don’t think they should be the majority, and they aren’t. It’s a pretty good balance, in my opinion, but I don’t think there’s commercial influence or bias at all. Clearly, we need to do something to dispel that perception, and that’s something we’re trying to work on during the coming year,” she told JAVMA.
 
Those plans may involve something mentioned in a letter sent to the USDE by Dr. Michael I. Kotlikoff, dean of the Cornell University College of Veterinary Medicine. He supports the creation of a joint accrediting body similar to the Liaison Committee on Medical Education, the accrediting body for medical schools.
 
The Association of American Medical Colleges and American Medical Association each appoints six professional members and one student member. The LCME itself appoints two public members, and a member is appointed to represent the Committee on Accreditation of Canadian Medical Schools.
 
“Such a separately incorporated body responsible for veterinary accreditation, constituted equally by the AVMA and the AAVMC, would better insulate decisions about academic standards and accreditation from political and legal considerations of the AVMA,” Dr. Kotlikoff wrote. He said it would also provide an opportunity to craft a more balanced and appropriate mechanism for membership selection than currently exists for the COE.
 
Currently, the AVMA House of Delegates elects 15 of the council’s 20 members. The AAVMC and Canadian VMA appoint one member each, and the COE elects three public members.
 
Dr. Kochevar, who is also AAVMC president, said her association agrees that the way members are appointed should be re-evaluated, although she expressed no concerns about the selection process.
 
“The current process is inherently with the HOD. The political process is not always driven by ‘Let’s elect the most qualified person.’ It’s driven by politics,” she said. “The goal is to assemble a group of people who are only there to assure quality education; they aren’t there for other reasons.”
 
At the annual deans’ conference in January in Naples, Fla., the veterinary college deans discussed various models of accreditation. On hand were representatives from the LCME to answer questions about the advantages and disadvantages of their accreditation model. Further discussion is expected at the AAVMC annual meeting in March in Alexandria, Va.
 
“The current system has served the profession well,” Dr. Kochevar said. “Where we are now, we’re asking questions about more major changes that would make the system better.”