Commentary: The rise of anti-intellectualism in veterinary education
We cannot underestimate the impact of a decline in quality brought about by the distributive model of clinical veterinary education.
It's astonishing how swiftly vocationally oriented veterinary colleges-which exist outside a biomedical research framework, minimize research training of students, and utilize a distributive model of clinical education-have been welcomed and enabled by accreditors, administrators and educators. Equally remarkable is how swiftly a national movement involving many sectors of the profession, practitioners in particular, has mobilized to call for a return to high-quality veterinary education, particularly the teaching hospital model.
In this commentary, I argue that the proliferation of veterinary colleges having limited or no research base, existing outside a community of scholars, and pursuing a distributive model of clinical education is undermining not only the fabric of American veterinary medical education but also the economic status and future of the profession at large.
Advocates vigorously defend this model as a bold educational innovation “aligned with the future needs of the profession and society.” I see it as just the opposite: a model done on the cheap-highly profitable to its purveyors who need not invest in a teaching hospital while offering the profession an intellectually impoverished substitute for authentic veterinary medical education.
With one exception (Calgary University Veterinary College), none of the colleges that lack an academic teaching hospital is located within a research university and none meets the American Veterinary Medical Association Council on Education (AVMA-COE) standard 10 requirement for research activities that integrate and strengthen the professional program. Also, I believe most are in noncompliance with COE standards 3 (physical facilities and equipment), 4 (clinical resources), 8 (faculty) and 9 (curriculum).
Absent a teaching hospital and high-impact research enterprise, distributive-model programs lack a crucially important intellectual foundation that combines teaching and research in a manner adopted by other health professions.1 In significant ways, these distributive programs evoke early apprenticeship training models that existed outside an academic university community. Thus they threaten to narrow the scope of veterinary education and degrade the stature of veterinarians as co-equal medical professionals within the broader context of medicine and discovery.
What I find most disturbing about vocational-type schools are their grave deficiencies in the basic science disciplines. Basic science provides the essential knowledge and intellectual platform for science-based practice of clinical medicine. This has never been more important, because biomedical science, across the range of basic translational and clinical research, is advancing at a breathtaking pace. I believe that Western students who spend the first two years largely on their own in a case-based learning program (a model that was abandoned by Mississippi State) graduate with scant exposure to the basic sciences. I believe that Ross students, taught by a nonresearch faculty, are being educated in yesterday's basic sciences.
Unlike medical students, veterinary students are not required to take a basic science exam after their second year, something that unfortunately most veterinary deans oppose. And the North American Veterinary Licensing Examination (NAVLE) is entirely clinical with the specific goal of passing the minimally competent entry-level graduate.
The distribution of students to questionably monitored private practices for clinical training puts their clinical education at great risk. This is not because private practitioners are incapable of teaching students many valuable things, some of which they may not encounter in a teaching hospital, but because in the critical third and fourth years, veterinary students require a very different learning environment, one structured to ensure that they acquire a strong conceptual and intellectual foundation as well as the basic skills essential for veterinary practice.
As a private practitioner for 11 years and as an educator-researcher and dean during the succeeding four decades, I have come to the firm conclusion that there is no substitute for a full-service teaching hospital where teaching, research and patient care are integrated; where students have day-to-day access to the broad spectrum of specialty disciplines; where world-class diagnostic imaging equipment, clinical laboratory instrumentation, a necropsy facility, and clinical and pathology rounds and conferences facilitate learning; and where interaction with veterinarian-scientists engaged in high-impact research exposes students to the thrill and joy of discovery. The latter is particularly germane owing to the increasing complexity of clinical practice in a time of quickening genomic, molecular and translational medicine and a widening gulf in knowledge, language and understanding between clinicians and basic scientists.
In a teaching hospital, students are more likely to learn that good medicine means science-based medicine practiced with uncompromising integrity and compassion, and that any lesser standard is synonymous with poor and even, at times, fraudulent medicine. And because a clinical teacher's primary objective is to prepare students to make their way without him or her, there is a real incentive to encourage students to question deeply, to appreciate the dynamic biomedical context of clinical science, to learn from failure and to become skilled at critical analysis and synthesis of information.
Students also learn in a teaching hospital that patient outcomes more often than not result from collaboration and that successful treatment crosses specialty lines. They are more likely to discover how the three stages of evidence-based medicine are applied and how basic molecular knowledge is transforming clinical practice. In a teaching hospital, students are more likely to become aware of their own deficiencies-for example, realizing that it's possible to do everything right medically and still have a negative outcome.
Today the practice of medicine is increasingly driven by diagnostic laboratory tests, powerful imaging techniques and expensive therapeutic modalities; it is tempting to cede one's autonomy to technological devices. It is in the teaching hospital rather than the high-volume private practice that students are most likely to internalize a first principle that must never be abandoned: that barring emergency situations (a cow with acute legume bloat, a dog choking on a bone, a cut artery in a horse), good veterinary care always begins with a thorough history and physical examination-with what one sees, hears, feels and smells. Also, it is in the teaching hospital environment that students will more likely appreciate the breathtaking pace of development of new biomedical knowledge and realize that they must keep learning in this constantly changing environment.
Unfortunately, there is no reliable evidence to demonstrate whether or not graduates of vocational-type distributive-model schools perform as well as, better than, or worse than than traditional-school graduates in practice situations. Anecdotal evidence, often effusively cited, is essentially worthless. Unlike human medicine, there is no system in place for measuring veterinary outcomes. In the complex entry-level veterinary employment landscape it is virtually impossible to obtain useful qualitative or quantitative data. Some graduates-perhaps most-will take jobs with excellent practitioners who love their profession and regard it as more than a business. Many will work for practitioners who view their profession solely as a business. Some will work for practitioners who practice poor medicine. Indeed, it is difficult even for veterinary schools, particularly those with distributive clinical programs where students are not under direct school oversight, to assess accurately the intellectual quality and clinical skills of the students they graduate.
Proponents of the distributive model in veterinary clinical education often point to the rotation of medical students through non–university hospitals or physicians' offices as a justification for distributed veterinary education. Two points are relevant here. First, unlike veterinary medical education, human medical education does not lead to clinical certification; all states require that medical school graduates successfully complete significant additional clinical training before they can be licensed. Thus, distributive teaching models in human medical education broaden the exposure of physicians prior to their specialty training often as a way to aid in specialty selection and wider exposure to medicine. Second, due to the advanced oversight and regulation associated with human medicine, experience in private or community hospitals generally involves exposure to physicians with advanced credentials and often with academic affiliations or appointments, a broader and more consistent experience than in private veterinary practices.
Having been a clinical department chairman and dean in a school with two teaching hospitals, I am well acquainted with the financial burdens they may impose and the one-dimensional argument that they are unaffordable and therefore doomed to extinction. I would counter that a university teaching hospital is an indispensable time-tested crucible for achieving excellence in clinical education and that the distributive model is leading the profession toward mediocrity and economic decline.
As distributive-model schools proliferate, little is heard about the obvious fact that a well-managed on-campus teaching hospital, once up and running, should be a significant revenue generator. Both outpatient clinics and hospitalized patients generate significant revenues, while clinical research programs generate grant and contract research dollars that support faculty and technician salaries as well as school overhead. Clinical trials, along with advanced veterinary care, can be steady sources of revenue, and endowed professorships for distinguished clinical faculty may free up funds for other purposes.
Along with adding prestige to the institution, a teaching hospital's public service functions (diagnostic, referral, clinical research, and client and professional continuing education programs) attract donations from the dog and cat fancies, the horse racing and breeding industries, grateful individual pet and horse clients, individuals with passionate interest in animal welfare, the pharmaceutical industry, the pet products industry and alumni. State appropriations also can contribute significantly, especially in support of equine and food animal research and services.
Deans in some veterinary schools argue that a full-service teaching hospital is unrealistic because the projected caseload is too small to sustain it. I believe this is a poor excuse. A good teaching hospital, human or animal, is a precious regional resource. Cornell's renowned hospital, for example, located in rural New York state in a city of 30,000, draws clients from across the state and beyond. In short, I believe the argument that teaching hospitals are unaffordable and therefore obsolete is bogus and a disservice to those teaching hospitals that are both advancing clinical medicine and helping their parent institutions financially.
Most important, though, is the fact that teaching hospitals are powerful magnets attracting the most gifted clinicians, interns, residents, veterinary and graduate students, and veterinarian-scientists. Another critical point is that teaching hospitals attract the most perplexing clinical cases, which are essential to challenging students' ability to develop and work through a differential diagnosis, consult the literature and learn to use laboratory tests and technical resources effectively and judiciously.
Since the fundamental components of veterinary medical education and allopathic medical education-including accreditation standards and the U.S. Department of Education's (USDE's) criteria for recognition-are virtually indistinguishable, how is it that so many in leadership positions continue to encourage and accredit schools that do not meet the accrediting agency's published standards?
There have been many enablers and contributors, but foremost among them are:
1. The Association of American Veterinary Colleges (AAVMC)
I believe that the AAVMC, essentially a deans' association, has failed to play a proper independent role as an advocate for appropriately rigorous and consistently applied accreditation standards. One reason is almost certainly the fact that the association includes deans from institutions that benefit from weak standards. A second reason appears to be a reluctance to oppose AVMA policies. The result is an organization that justifies the accreditation of schools that fail to meet traditional academic standards while insisting, despite compelling evidence to the contrary, that COE decisions have been “standards-driven and evidence-based.”
It is inconceivable to me how the AAVMC's North American Veterinary Medical Consortium's Roadmap for Veterinary Medical Education in the 21st Century, published in 2011, failed to examine critically the current and long-term impact of the proliferating distributive model on the quality of veterinary clinical education. Nor did the lengthy Roadmap Report acknowledge that the AVMA-COE's rapidfire accrediting decisions, domestic and foreign, had in fact already set in concrete a dangerously regressive roadmap.
Because many veterinary deans in schools with teaching hospitals contract to provide clinical training for students from incomplete schools or schools that fail to meet rigorous academic standards, they enable such schools to exist and thrive financially while flooding the job market with entry-level graduates, most with staggering debt burdens.
At the December 2014 meeting of the USDE's National Advisory Committee for Institutional Quality and Integrity, a half-dozen deans, in remarkably similar statements, unreservedly endorsed the AVMA-COE's decisions, seemingly unconcerned that, as a result, their own graduates are now receiving a devalued DVM/VMD degree and their alumni will be competing with a fast-growing surplus of entry-level practitioners. Only two deans (Cornell and Louisiana State) had the insight, long-term perspective and courage to support separating the COE from the AVMA.
Also, veterinary deans have failed to recuse themselves from serving on the COE or participating in the selection of COE members despite real or apparent conflicts of interest. And despite real or apparent conflicts of interest, some deans serve or have served on the board of directors for Banfield Pet Hospital, a company that has invested millions of dollars in vocationally oriented schools and employs large numbers of their graduates.
2. The AVMA Board of Directors and Council on Education
Despite some very positive incremental changes, a firewall between the AVMA Board of Directors and the COE does not exist. The board has not yet surrendered its practice of appointing the committee that selects COE members. Nor has it provided the COE with its own budget, staff, workplace and legal counsel. In an apparent gesture to appease its critics, the AVMA has offered the COE $10,000 with which to hire its own legal counsel, but those familiar with engaging high-quality counsel will appreciate that this will buy only about 20 hours of legal assistance.
In conclusion, distributive-model veterinary schools that fail to meet traditional academic standards pose a grave and urgent threat to an educational system that, in a span of five decades, had evolved from mediocrity and a trade school mentality to cutting-edge standing in education, research and clinical practice, on a par with human allopathic medicine. In these advances, teaching hospital clinicians and veterinarian-scientists led the way by integrating teaching, research and patient care, establishing high-impact comparative and translational research programs, and rapidly developing a broad spectrum of authentic clinical specialties.
I believe that the dumbing down of the educational system with vocationally oriented schools whose only purpose is the production of large numbers of entry-level graduates and that contribute little or nothing to the creation of new knowledge and technology are a growing menace to the profession's future and its reputation as a learned and respected medical profession. Also, such schools have little or nothing to contribute to the urgent global issues of One Health, food animal production systems, food safety and security, biodiversity, environmental protection, and the advancement of the sciences undergirding human and animal health.
I fear that nothing substantial will be done to stem and remedy this appalling situation until an autonomous, independent and courageous accrediting agency-with its own budget, staff, workspace, and free access to its own legal counsel, wholly separated from the AVMA and AAVMC and determined to consistently enforce compliance with toughened standards-replaces the present Council on Education. Only then will the rising anti-intellectual tide in veterinary medical education begin to recede.
1. The Flexner Report, an extensive study of medical education in North America, is highly critical of vocational medical education. See archive.carnegiefoundation.org/pdfs/elibrary/Carnegie_Flexner_Report.pdf.
Dr. Robert Marshak is professor emeritus of medicine and dean emeritus for the University of Pennsylvania School of Veterinary Medicine. He can be reached at firstname.lastname@example.org.