Back after a century, for-profit medical schools could make impact

February 23, 2017

PROVIDENCE, R.I. [Brown University] -- More than 100 years ago, the influential "Flexner Report" on medical education decried the then-prevalent model of for-profit medical education, leading to its complete disappearance from the United States for decades. But just recently, for-profit medical education has returned, note three Brown University scholars in a new JAMA article that considers what the revival might mean.

"It's not so much that we're in favor of it," said Dr. Phil Gruppuso, professor of pediatrics in the Warren Alpert Medical School and former associate dean for medical education. "We are merely documenting that it's happening. We hope that it can make a positive contribution since it's going to happen."

The turning point came in 1996 when antitrust litigation against the American Bar Association forced it to accredit for-profit law schools, wrote co-authors Gruppuso, Dr. Eli Adashi, professor of obstetrics and gynecology and former dean of medicine and biological sciences, and current Brown medical student Gopika Krishna. Legal advisors for the Liaison Committee on Medical Education, which accredits allopathic (M.D.-granting) medical schools, took notice. By 2013, LCME had abandoned its prohibition on accrediting for-profit schools.

At one time, the country had only one for-profit medical school: the Rocky Vista University College of Osteopathic (D.O.-granting) Medicine in Colorado, which opened in 2007. But the first allopathic for-profit school emerged in 2014 when Ponce Health Sciences University School of Medicine in Puerto Rico was acquired by the for-profit public benefit corporation Arist Medical Sciences University. Since then, two more schools have attained accreditation. There are now nearly 500 students in the for-profit medical class of 2020.

Modern accreditation standards mean that many of the Flexner-era ills of for-profit education -- little or no requirements for admission or graduation and lax attention to instructional quality or attendance -- are long bygone, the authors wrote.

But acceptance of for-profit medical education is still far from universal, the article states. In fact, Adashi and Gruppuso said that many fellow medical educators still haven't realized that for-profit instruction has returned.

"It's a fait accompli, although most people don't know that," Adashi said. "They are very surprised to hear it."

Instead, the widespread presumption of the field is that medical education is exclusively not for-profit oriented.

"Additional reputational challenges faced by the new for-profit medical schools stem from the view that medical education is an inviolable public good that is ethically incompatible with the for-profit motive," Adashi, Krishna and Gruppuso wrote.

The schools, for example, will have to do much better than some for-profit colleges outside of medicine that have recently become entangled in commercial failures and scandals, they said.

What they could contribute

Because for-profit medical schools are not tied to research universities, they may be more hard pressed to offer students exposure to making scientific and medical advances, Adashi said. But he acknowledged that research pursuits, while important, may at times lead to distractions from teaching. Limited to just the classroom, for-profit instructors might be in a position to accomplish the mission of graduating competent licensable physicians who can assist in closing the nation's physician shortage, Adashi said.

The absence of research might pose another narrow advantage for for-profit schools, Adashi and Gruppuso said: a lower cost structure. Were schools, despite their profit motive, to use these lower costs to charge lower tuitions, they could address the serious problem of medical student debt. But so far data suggests that for-profit schools are not charging lower tuitions or offering more generous scholarships, they said.

"Finally, new for-profit medical schools could distinguish themselves by committing to innovation in undergraduate medical education in the best tradition of the private sector and in the spirit of a market economy," the authors wrote.

But to do any good, given that they are for-profit schools, they'll have to show they can operate in the black, Gruppuso said. He has doubts.

"The tuition-based business model, if that is what it is, remains puzzling," Gruppuso said. "It's not nearly clear that a medical school, properly structured and meeting all the accreditation requirements, can actually make money."

Brown University

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