Update on the ABA's New "Diversity" Standard:

The Michigan Daily has an informative (albeit, as you might expect, rather Michigan-centric) story on the standard, noting criticism by me that the standard is intended to and will have the effect of requiring some law schools [the author says "small"; I tried to get across "resource poor" and "non-elite"] to break the law. The article also contains interesting quotes from Michigan Law School Dean Evan Caminker, who is critical of the ABA's growing tendency to micromanage law schools.

I've heard that many law school deans have become fed up with questionable and expensive policies imposed on them by the ABA, including pressure to tenure law librarians, clinicians, and legal writing professors; pressure to keep even non-"productive" faculty members' teaching loads low; pressure to limit the use of adjuncts; pressure on law schools that have tried their darnedness to attract minority students to spend more and more of their scarce resources on that goal; and so on. If the ABA leadership thinks that the law school establishment is going to rally to its defense on the "diversity" issue, I think it is sadly mistaken. Having abused its accreditation powers for so long in so many ways, there isn't much of a reservoir of support for the ABA to call on.

Relatedly, the ABA's authority to accredit law schools for federal law purposes for is up for renewal at the Department of Education. I learn from John Rosenberg, via the Chronicle of Higher Education, that the Center for Individual Rights, Center for Equal Opportunity (text here), and the National Association of Scholars (text here) have all written to the DOE arguing that unless the ABA is willing to give up its new, illegal diversity rules, reaccreditation should be denied. The Rosenberg link contains some choice quotes.

The Center for Equal Opportunity has also asked the DOE to procure the help of the Justice Department in investigating the ABA for violating federal law.

I'm beginning to think that the ABA has seriously overplayed its hand, and the result may be a weakening of its stranglehold over legal education that goes well-beyond its authority on the "diversity" issue.

RKV (mail):
Would someone please remind me why we need to accredit schools in the first place? Particularly, why do we accredit professional schools where tests like the Bar exam are required to practice? We certainly had lawyers before law schools were accredited - some fine ones like John Marshall and Learned Hand to be specific. Post-secondary accreditation started in the 1960's and it sounds to me like it doesn't add value to the higher education system and should be dropped.
3.10.2006 8:34am
Dusty (mail) (www):
RKV, accreditation doesn't add value, per se, to the university, it adds truth to it's advertising that the school does indeed measure up to a standard. It's primarily for information for the buyer, not the seller.

David, I'm curious about a few things. One, what laws could be considered that the ABA has broken? Some aspect of incitement laws? RICO? If an offense was deemed to have been committed, how deep might the State delve into prosecuting members? Lastly, has there been any precendent for this kind of action?
3.10.2006 8:56am
As a student at a, shall we say, non-elite law school, I am very concerned about the effect this policy will have on low-tier schools. Reasonable minds can differ on the value of affirmative action, but this policy is so bizarre that I can't help but wonder if it is a deliberate attempt to inflict damage on non-elite schools. Does anyone know whether the ABA tends to favor elite schools in its policies?
3.10.2006 9:16am
RKV (mail):
Dusty, Bar passage rates trump anything in an Accreditation Report. Same could be said passage of state medical exams.
3.10.2006 9:16am
Cathy (mail) (www):
I'm beginning to think that the ABA has seriously overplayed its hand...

I think so too. Last year I took issue with its rules micromanaging students' courseloads. As a result I've refused to renew my student membership, and will think long and hard about ever becoming a "grown-up" member. Unless I think I can change it from within, I probably won't.
3.10.2006 9:29am
Dave Hardy (mail) (www):
I've always had a problem with the idea of accreditation.

In most states, to take the bar (a completely understandable requirement--a practical test of knowledge) you must first have a JD, and it must be from an ABA accredited school. ABA is a private, voluntary organization, to which I suspect the majority of attorneys do not belong (I certainly don't). It can impose any requirements it desires, and enforce them any way it wants, without regard to due process, equal protection, or any other standards. What is the basis for making government-issued licenses depend upon approval of training by a private, voluntary organization? Let alone one in which most of the regulated profession does not belong?
3.10.2006 10:05am
Houston Lawyer:
It would be interesting to see the results of the ABA yanking the accreditation of a high ranking law school based upon some completely bogus standard such as failure to adequately discriminate against white people. I think a class action lawsuit by all of the students enrolled at that school would be highly appropriate. Lost wages plus tuition and board wasted for hundreds of students would add up quickly. Then there are punitive damages.
3.10.2006 10:30am
ak47pundit (www):
The ABA accreditation process itself is also problematic,

The most diverse lawschool in the US (save Puerto Rico) is Thomas M. Cooley lawschool in Michigan.

Cooley is trying to operate satellite campus in Oakland County Michigan and Grand Rapids, Michigan and the ABA is refusing to accredit them and even fails to follow the ABA's own accreditation procedure in trying to block the accreditation.

The case just went up on oral argument in the Sixth Circuit.

For more info see Cooley Sues ABA for Blocking Accreditation of New Satellite Programs that Meet All Standards

Ironically, the ABA is preventing the growth of a diversity-rich law school by blocking these two-year sattellite programs.
3.10.2006 10:40am
JWS (mail):
Sadly, the ABA long ago ceased to be representative of the bar. Less than 50% of lawyers belong. It is now little more than a political action committee.
3.10.2006 10:47am
Richard Riley (mail):
David's posts on the ABA diversity standards have been right on the money, but I wonder about his suggestion that the ABA has overplayed its hand and the law schools may push back. Isn't it at least as likely that the ABA accreditation committee is a stalking horse for the administration and faculty of establishment law schools, who want some cover for maintaining race-based admissions policies which probably violate Grutter?

I actually don't accuse those schools of acting in bad faith. My wife is on the UVA law faculty, and much of the sentiment there - and I suspect at many law schools - in support of race-based admissions is a strongly felt need to generate more minority attorneys with degrees from top law schools. Those law schools may be kidding themselves about the desirability of what they're doing (cf the Sander study among other objections), but they definitely believe in race-based admissions and are prepared to go to some lengths to maintain it.

So I'd like David's thoughts on whether the ABA isn't actually doing exactly what the law schools (not GMU and its allies but nevertheless most law schools) want. You have to admit that "accreditation" requirements could help support a defense against more challenges to race-based admissions.
3.10.2006 10:59am
Mikeyes (mail):
For those of you who have problems with accreditation, just read the Flexner Report. In 1910 the Carnegie Institute asked Abraham Flexner (a non-physician) to visit every medical and osteopathic school in the country, many of which were non-affiliated or only loosely affiliated with universities. You can read the details, but after this report, over half of the schools were disbanded due to lack of competence. Most of the schools dinged by Flexner were only in existence to make money from the fees. Read the report, it points out that there were too many doctors and the reason for this was that there were too many medical schools. The majority of these medical schools did not meet basic standards academically or physically. Flexner stated so in brutal terms.

Even in the early '70s rumor had it that if you gave $5000 to the right official, you could get a license in Florida. At that time, Florida did not participate in any of the national tests and you had to take their so-called test. In the early 1910's there was even more corruption in the licensing process. Accreditation helped clear all of this up.

My problem is that having the ABA accredit and be the professional governing body at the same time is like having the fox guard the henhouse. The AMA won't do it (although they have a say in the process) and if the licensing boards were not present, a single body with all the power is liable to be corrupt or dictatorial. Or both.

If an independent accrediting body with some oversight was set up, then maybe law schools would be more honest in their admission policies and their goals and maybe a few of them would not survive. Right now there are 54K admissions to law schools every year (out of 90K applicants, better than 50%), a prevailing attitude that only 14 or 20 or 50 (depending on where you graduated) law schools produce "good" lawyers (even though most law school graduates who persist pass the bar), and a 25% rate of not taking the bar for those who manage to get through school. Surely there is some room for reform here, but the ABA is not interested. And why should they be? The more lawyers there are, the more money flows in the coffers. Why restrict the numbers?

A clear conflict of interest.
3.10.2006 11:03am
MDJD2B (mail):
The most diverse lawschool in the US (save Puerto Rico) is Thomas M. Cooley lawschool in Michigan.

Do the schools in Puerto Rico have students from many diverse cultural and ethnic backgrounds? It's good t know that they can find so many non-Hispanics who are fluent enough in Spanish to get through law school.
3.10.2006 11:14am
DavidBernstein (mail):

The Flexner report is much more controversial than you think, and did not have wholly salutary consequences. I note in my book Only One Place of Redress, that the Report led to the closure of the only medical schools in the South (except Howard) that admitted black students, including schools that had produced some very prominent black doctors. There was reason to believe that these schools needed improvement, but also reason to believe that they could have improved if given the chance, but the authorities had decided that only Howard should survive among the medical schools catering to blacks.

More generally, Flexner created the completely unnecessary requirement of four years of college before medical school, which has wasted billions of dollars in opportunity costs and actual costs, while favoring those with the substantial resources needed to get through eight years of school.

And so on.
3.10.2006 11:19am
Well, I tend to agree that the ABA has overplayed its hand, since as a pro-affirmative action liberal I still pretty much roll my eyes at these recent efforts. I don't agree that they have joined the UN on the roster of useless organizations that need to be razed to the ground, but I do wish they would cool it.

As a Michigan native I find the ABA-Cooley conflict interesting. The ABA may be messing with the wrong school as Cooley is extremely well connected politically.
3.10.2006 11:24am
JunkYardLawDog (mail):
The ABA has been nothing but a left wing PAC since the early 80's, and it gets worse every year. I'm not in the habit of supporting left wing political organizations so I resigned my membership in the mid '80's because I was fed up with the ABA making affirmative policy statements on constitutional legal principles that were far from well settled law.

I think a federal law should be passed that strips the ABA from its monopoly on accrediting schools. There is nothing wrong with voluntary school accreditation, the ABA just shouldn't have a government imposed monopoly on the process. Other competing organizations should be allowed to accredit law schools. Organizations that accredit other colleges and universities for example. New organizations that have never accredited a law school or any college at all. Then the marketplace will sort out which accreditations are important or not. No client ever asks their lawyer if they went to an ABA accredited school. They just want as good a lawyer as they can get for the price they are willing to pay.

I also think the ABA should not be the only group of lawyers asked to opine about and testify about the qualifications of nominees for federal judgeships, and measures should be taken to deemphasize their importance in the process. If I were in the senate I wouldn't even vote to call the ABA as a witness to opine on a nominee's qualifications.

Says the "Dog"
3.10.2006 11:33am
I also think the ABA should not be the only group of lawyers asked to opine about and testify about the qualifications of nominees for federal judgeships

Now this is sheer genius. Someone should get on that right away. Why, it sounds like the kind of thing that should have been done long ago.
3.10.2006 11:56am
Per Son:

It is up to each state to determine who can sit for a bar exam. For example, Ohio requires ABA accredation, but California does not. Why would want a federal law to govern something that concerns a purely state issue - licensing of professionals?
3.10.2006 11:56am
Mikeyes (mail):

If you read the report, Flexner (and the Carnegie Institute) were very aware of the problem of the education of black doctors. There is a whole section on it and he explains why he dinged the schools (they offered an inferior education.) In addition, he also thought that Meharry was a fine school along with Vanderbilt and if I remember correctly they were the only schools in Tennessee that past muster. I think Meharry is farther south than Howard if I remember my geography. ;~)

As for the four years requirement, my experience with six year graduates (combined BS and MD) and with the English system (I spent a three month clerkship at St. Mary's in London) is that students out of high school are able to do the work but often are not very mature - it is possible to be too young to qualify for some medical licenses if you are educated in this manner in some states. The other advantage of a four year bachelor degree is that members of underserved minorities have some time to overcome educational deficits imposed in high school and are able to tackle the immense amount of work that medical school demands. The studies show that if you are able to get through the basic courses (the first two years), even with less than average grades (and remember that we are not talking law school here, my class averages were 89% low to 94% high, no curve), you will do well in the clinical years no matter what race or category. I contend without any proof at all that those four years help marginal students once they are in medical school.

Otherwise we would have to rely on a national test the way virtually every other country except Canada and Dominica do. And we are already aware of the problems with that. I opine that medical school would become more exclusive, not more inclusive in that system mostly because it is very expensive to go to medical school. Not only would the schools want to insure results similar to what we have now (99% pass rate on national or state boards and graduates practicing medicine)but the students who have to pay for this, would be more reluctant to try if funding was iffy. The choices would be to lower standards to make sure that there are more graduates (people drop out of medical school for many reasons, most of them not academic) which would result in poor medical care, especially amongst minorities, but greater costs at the practicing end.

The six year programs brutally weed out the poor students in the first two years and the costly part of medical school is filled with bachelor's degree graduates. This is not a bad alternative but most schools are reluctant to go that route as they often see better prospects later on. The average first year student is now about 25 which means that the majority of these students have life experiences and/or graduate degrees.

Granted law school and medical school have little in common as far as the aptitude of the students and the outomes of the education. (This is not a dig, the schools serve two different purposes. You don't have to be that smart to be a doctor, you just have to be able to do the work in school, which is daunting. And you can't faint at the sight of blood unless you want to be a psychiatrist, like me.) ;~) But I think if you have a goal of a diverse student population and by extension a diverse population of professionals, you have to make sure that the best chance is there for under-represented minorities to succeed. That won't happen out of high school.
3.10.2006 12:06pm
More generally, Flexner created the completely unnecessary requirement of four years of college before medical school, which has wasted billions of dollars in opportunity costs and actual costs, while favoring those with the substantial resources needed to get through eight years of school.

A friend of mine went to medical school in Ireland. There, medical school is right out of high school and about five years long to cover the basic sciences and all medical school stuff. My friend got credit for undergrad to some degree, but all her classmates were as young as 19 or 20!

Why isn't law an undergraduate degree?
3.10.2006 12:09pm
DavidBernstein (mail):
Mike, I encourage you to read the relevant chapter of my book, which you would find of interest. Here's a small excerpt:

Meanwhile, ever-increasing pre-medical educational requirements made it difficult for students from impoverished backgrounds to achieve the financial wherewithal to attend medical school. Flexner argued that his recommendations for additional pre-medical education would not discourage poor students, because non-profit medical schools, subsidized by foundations and alumni, would be able to offer six years of education for the price that for-profit schools charged for four years of education. Apparently, Flexner not only had excessive faith in the efficiency of non-profit institutions, but also was not familiar with the concept of opportunity costs; the prospect of an extra two years of lost wages could easily divert a promising student but impecunious student from medical education to a more immediately remunerative endeavor.
3.10.2006 12:20pm
Thief (mail) (www):
Here's a quick thought: If it's lawyers you're training, why not let each state bar (or even judicial conference) accredit the schools?
3.10.2006 12:40pm
ak47pundit (www):

Apparently the law schools in Puerto Rico are considered the most diverse as it is practically 100% minority. Minority enrolment of course = diversity. Of course I can't find the quote but here;'s an interesting U Dayton study on whiteness at law schools with Puerto Rico having a -99.9% (yes negative) "Excessive Whiteness score, and they came in pparently they made 184/185 with the second least amount of whiteness. Pontifical Catholic University of Puerto Rico getting the perfect -100% excessive whiteness and coming in at 185 of 185.

Amazing to think people are studying the presence of "excessive" whiteness at law schools eh?.

Note also that Cooley does not have an AA program. To get in its strictly your LSAT score + (your GPA x 15) = your admission score which needs to be over 185 with a minimum LSAT of 142. basically its an easy school to get into but a hard one to stay in.
3.10.2006 12:44pm
Note also that Cooley considers itself a better law school than University of Chicago, Duke, and Stanford.

Its rankings are based, in part, on the ever-important statistic "libarary carrels per student."
3.10.2006 1:35pm
Mikeyes (mail):

I don't disagree with your conclusion, but where is a poor black woman going to find $250,000 to finance her education out of high school? And how will she convince an admissions committee that she can hack it in medical school if her school consistently ranks as one of the worst in the state as far as drop-out and graduation rates go? And what if she scores a 1030 on the SAT? She will be at a disadvantage trying to get into a school in which the classes are populated by very succesful (academically and in every other way) students, most of whom have middle and upper middle class educations and some access to funds. Most medical students live on loans which they qualified for by having a credit record, rich parents, or other assets.

There are state schools that have the six year programs mentioned. Wisconsin (where I live) has one that is very hard to get into and open only to WI residents who qualify. Once accepted to the program you have to keep your grades at a certain level, take the courses recommended by the school, and work your ass off. It is not easy, but the rewards are worth it. An educational experience is lost in the shuffle, you are simply in trade school at that point, but you can become a doctor.

The Tulane study of pre-med students showed a dropout rate of two-thirds by the time one had to apply to medical school. This year there were 37K applicants and 17k students accepted which means that one sixth of those who started out as pre-med made it into med school. Of course this is not the same as being accepted into a medical school right out of high school, but if we had a six year model, how many well meaning students would drop out once the hard work began? Right now the dropout rate in medical school is very low.

I am all for six year schools and I think they offer a good opportunity for state run schools to get more bang for their buck. But in England, for example, you are not going to be anything but an outpatient physician unless you finish in the top ten percent of your class. And the state controls the numbers of physicians and where they work in a much tighter way than in this country. Still, if you look at who is a doctor in that country, there are very few minorities other than East Asians due to the admission requirements.

When Flexner wrote that report, anyone with the tuition could go to a medical school. Most of the schools were "Joe's medical school" at one time (including some very famous Ivy League schools) and when Flexner wrote the report there were schools that had no hospital affiliation (Stanford was given just a conditional pass because of this), no labs, no patients, and virtually no doctors teaching. Some schools were companies that traded their stock to anyone who wanted in on the profits and even those schools affiliated with universities (the University of Arkansas school at the time) had no relationship with the faculty or administration of the school. They just paid the school to use the name. Some schools used the name without permission.

As a result, not only were there too many physicians, but most were not qualified to practice. Flexner uncovered a lot of corruption in the licensing field, he was especially incensed about Illinois, and made no bones about the consequenses of what he saw. In hindsight, I suppose that you could fault some of the things that he proposed. His was a very powerful report that changed the face of medicine and enhanced research. Since then there have been many changes not related to the Flexner report that make becoming a doctor more exclusive intellectually and harder just from a point of view of work.

In 1910 many prominent doctors (including some of those black doctors you mentioned) went to medical school for a few semesters (all they could afford to do) and finished up as an apprentice. This was possible because the total body of knowledge was about 2% of what it is now and the effectiveness of physicians was limited. About this time the apprenticeship programs were fading out and the Johns Hopkins model was taking over. Most of the fly-by-night for profit schools knew this and that is one reason why they died out. (Another was that state legislators read the report and acted accordingly.)

The cost of going to medical school now is astronomical compared to what it cost in 1910 especially considering that a medical education is a minimum of 7 years. (I know, an argument for the shorter time in school.)

In a perfect state (WI may even qualify) such a student, assuming he or she does not drop out, would benefit from grants and scholarships in undergraduate school. In many states, you can have debt forgiveness if you promise to stay in an underserved part of the state for a given amount of time and attend the state medical school. The Armed Forces offer a similar deal. So it is possible for a good student with no money to find a way to pay for this education even in a system fostered by Abraham Flexner. And in these circumstances the cost differential is not that much, mostly cost of living, and a poor student may have a better chance to get into medical school, or at least find out if that is what they want to do.

I do need to read your book (can you give me the cite again, just email me, thanks) before I comment any more. (Good thing I am not longwinded.) but I would like to opine on my original point which is that law schools do not seem to be producing lawyers at any great rate, yet they are everywhere. Are there too many lawyers? Is the educational system and by extension the accreditation system, part of this? Are there reasonable solutions like a five year law degree from undergraduate schools? How many "Joe's Law Schools" are there out there, if any? And is the ABA the right organization to deal with this at all levels the way they do now?
3.10.2006 1:41pm
Frank Drackmann (mail):
I've never had to take a state test for medical licensure, just the 3 parts of the national boards, taken after the end of the 2d and 3rd yrs of medical school, and the final part taken during the internship year. The number of U.S. Medical School positions has been stagnant for the last 30 years, with only a few new schools being opened and few class sizes being increased.
3.10.2006 1:50pm
John Steele (mail):
The law schools rebelling at the ABA's accreditation power? Maybe a quarter-rebellion, but never a real one.

The ABA is the cartel-creator and cartel-protector for AALS. Indeed, The ABA is still under a price-fixing consent decree for its misuse of accreditation powers to fix professor salaries. (US v. ABA, 934 F.Supp. 435 (D.D.C. 1996)) So the real complaint must be that the ABA is managing the cartel poorly, right? I'd be surprised (but pleased) to hear that a complaint from the law schools is that the ABA shouldn't maintain the law school guild. Everyone familiar with the history of the ABA's control over law schools and with the rent-seeking behavior of professions in general, knows that the ABA's accreditation power is what makes law schools happy and wealthy.

The deans want the cartel, because it provides professor salaries 3x or 4x the salaries other humanities profs earn, because it requires large buildings and ample resources, and most of all because it precludes the study of law the way it should be structured: as a dual-track process for either undergrads or graduate students, at the students' option. (We really need to bring back the LLB for undergrads and the first school that does it may earn a huge first mover advantage.)

Understandably, the deans don't want micro-management. But in the absence of effective cartel power wielded by the ABA, the danger is that 80% of the law profs would be lecturing black letter law to 18 year old, and earning the salaries that History or English profs earn. Do the law schools really want that? The students would love that option, but the law schools would fight that tooth and nail.

So, the smart money is on the law schools to rock the ABA boat, but only very gently.
3.10.2006 3:35pm
Dilan Esper (mail) (www):
I don't know enough about this issue to know if what the ABA (which I am a member of) is doing is good or bad, though I am always suspicious that much of what professional guilds do is intended to limit membership in "the club" and push remuneration for "club" members higher. So I am sympathetic, at least in that respect, to Bernstein's point.

Nonetheless, I doubt that the ABA is really "overplaying its hand", so long as ABA accrediation is accepted by STATE bars as sufficient to skip graduates of such schools several steps ahead in the process of becoming a lawyer. Even if the Department of Education strips the ABA of its accreditation role for federal purposes, schools will still seek ABA accreditation, because without it, it will be harder for their graduates to get licensed by states to practice law.
3.10.2006 4:01pm

The deans want the cartel, because it provides professor salaries 3x or 4x the salaries other humanities profs earn, because it requires large buildings and ample resources, and most of all because it precludes the study of law the way it should be structured: as a dual-track process for either undergrads or graduate students, at the students' option.

Law professors earn more than humanities professors because they have a higher opportunity cost. Humanities professors have no real marketable skills.
3.10.2006 4:32pm
John Steele (mail):
The accreditation process provides signficant price protection for law professors. It may be that in the absence of those protections, law profs would still earn more than English profs, but the price competition would signficantly drive down price.

For example, in the absence of ABA accreditation standards, far more courses could be taught by non-tenured adjuncts working on year to year contracts, as is the case in other disciplines; professors could offer to teach heavier course loads; etc. Just read Chapter 4 of the Standards, and you will see how much price protection is mandated.
3.10.2006 4:51pm
JunkYardLawDog (mail):
Per Son, you are correct that its mainly a state law question historically. A federal law could govern admission to practice in all federal courts, bankruptcy courts, etc., even for lawyers not meeting state's state court requirements for admission. That would put a lot of pressure on the state's over time to conform or rethink their state court admission requirements.

There could probably be a federal law under the commerce clause to provide rules governing the interstate practice of law, lawyers from one jurisdicition with clients in multiple jurisdictions being protected in their ability to represent those clients even in state courts, irrespective of state law requirements regarding admission.

However, being a conservative, these federal law solutions rub me the wrong way to some extent. I was ranting a bit in my previous post because I think the ABA could be a great organization if it stayed out of political matters and focused on helping lawyers be better lawyers a heck of a lot more than it does now.

Says the "Dog"
3.10.2006 8:15pm
JLR (mail):
Based on my (admittedly incomplete) knowledge of medical school admissions policies, the Wisconsin six-year program (which is highly competitive) that Mikeyes mentioned seems like a good alternative program for those who are oppressed by the opportunity costs of the system. Having such programs be highly competitive ensures that only those with the intellectual focus and drive to get a BS and MD in six years do so.

But generally, I don't see much of a problem having the general requirement be that those who wish to get MDs be compelled to get a college diploma, thus making medical school admissions a separate endeavor after the undergraduate degree is obtained. It allows students to have the chance to explore various disciplines as an undergraduate, and allows them to move beyond what may have been pressure since early childhood to "become a doctor." Students can major in, say, music, while fulfilling pre-med requirements; this enables such students to see if their love of music should become a career, or whether it should just be a pastime. By fulfilling their pre-med requirements while pursuing a major in music (or art, or English lit, or fill-in-the-blank), such students can still attend medical school without bypassing serious exploration of all their interests.

Also, when many medical students live on loans and grants to begin with, the extended period of education seems less of an economic burden generally. If the fact that the general requirement to get an MD is eight years of education (instead of six) leads to much higher rates of med school graduation (as Mikeyes implies above, if I understood his posts correctly), then it would seem that the extra time in school pays off.
3.11.2006 10:45am
JLR (mail):
Btw, I should clarify something that was ambiguous from my 3.11.06 10:45 am post: Mikeyes never says that it is a "fact" that eight years of education (instead of six) leads to much higher rates of graduation from medical school. Therefore, I should not imply the conclusion I post is correct from an empirical perspective (the conclusion being that it would seem the extra time in school pays off). But based on my (admittedly incomplete) knowledge of medical schools, as well as the content of Mikeyes's posts, it would seem to accord with common sense that it makes the system work better to generally require receipt of a college diploma in order to attend medical school.

Thanks again.
3.11.2006 10:55am
Bruce Hayden (mail) (www):
A couple of days ago, I had a long talk with a couple of docs involved in hiring physicians, etc., and one pointed out that their accrediting body not only determines what schools can be accredited, but pretty much how many students each school can teach. This is apparently based on periodic studies of the need for doctors. If a school can't show need for more doctors, it can't open and, if open, can't increase class size. Of course, as an outsider, what jumped out at me was that it was inherantly aimed at keeping up physician salaries through the maintanance of their guild.

Nevertheless, apparently in the 1990s, they seriously underestimated the upcoming need for doctors, and, as someone above pointed out, didn't increase the number of graduating doctors when given the opportunity to. Unfortunately, they didn't take into account a number of factors, including that women (1/2 of graduating MDs) don't work as long or as many hours as men, and that many docs have cut back to 40 or so hours a week (apparently initiated by Gen X, but enthusiaatically picked up by their older brethern). So, with the impending retirement of a lot of baby boomer doctors, this doc predicts a major crisis in our health care system through a coming major shortage of doctors, all as a result of their accrediting board limiting the number of new medical schools and class sizes in currently accredited schools.
3.12.2006 11:36am
Bruce Hayden (mail) (www):
One of my pet peeves about ABA accredidation is their stand on adjunct profs. Some of my best classes were taught by adjuncts. They tended to bring real live experience to their teaching, and often used this to make subject matter more relevant than their full time brethern ever could.

Of course, this to some extent comes from the problem that law schools are trade schools cloaked in academic theory. The result is that you have 90% of us going out to practice law totally unprepared, because most of our profs never practiced that much law, and, indeed, look down on us who do.
3.12.2006 11:44am
JLR (mail) (www):
I do not have first-hand knowledge of the way medical schools operate. But based on Mr. Hayden's comments, I wish to provide information that I have gleaned that might shed more light on the situation.

Adding more medical students (because medical schools want more revenue from tuition, or for whatever reason a med school dean might have) would create a whole new set of inefficiencies -- inefficiencies that, given the nature of medical care, may be less desirable than the current set of inefficiencies present.

Based on anecdotal evidence, it is currently very difficult to find rotation placements for third and fourth-year medical students (much less for residencies and fellowships after medical school). Clinical faculty who are capable teachers of third and fourth year medical students are in short supply. Moreover, one cannot just give an attending physician three extra med students and hope for the same level of teaching quality for med students or, much more importantly, the same level of care for their patients.

For anyone who has ever been an inpatient or outpatient at a teaching hospital, it is painfully obvious how many times a patient has to keep telling and retelling his narrative of symptoms -- first to the med student, then to the resident, then to the fellow, and then to the attending physician. Even worse, sometimes the attending doesn't even bother to ask the patient directly about his symptoms, and instead relies solely on the resident or the fellow for information. This can lead to a game of "telephone" in which the patient's health hangs in the balance.

Imagine this "telephone" game being exacerbated because of extra med students being put on the same rotations.

Sometimes it comes down to normative judgments about the way patients should be treated.

At a place like Harvard Medical School, which has tons of quality attending physicians at approximately eight hospitals, adding extra medical students would not be much of a problem. But for places where there aren't many quality teaching faculty or many quality clinical rotations, adding extra medical students would create a major supply-and-demand problem in the third and fourth years of med school.

Sometimes, the inefficiencies created by a command-and-control system are preferable to the inefficiencies created when an imperfect market is left to roam free. Such normative judgments are beyond the realm of pure economic analysis, and are dependent on understanding the nature of the given field (in this case, medical care). It would seem the current medical school system is preferable to one in which quality clinical faculty are burdened with extra medical students.
3.12.2006 1:45pm
Bruce Hayden (mail) (www):

I would suggest though that a lot of the problems that you are talking about are a direct result of the command-and-control system in medical education. In this case, they result from faulty conclusions at the top made a decade or so ago, and are seen in the bottlenecks that you point out.

I will submit that if it pays to go to medical school, then there will be excess demand for the product. If a medical school doesn't get enough infrastructure in place to give its third and fourth year students the education they need, then they won't get students - which is why they will have an economic incentive to do just that. If the students aren't getting the requisite training, then they won't get into decent residencies - which will become known very quickly.

Of course, that is another bottleneck - residencies. My understanding is that at least some of most residencies is paid for by the govt. - so failure there is again a failure of command-and-control. But, again, if the command-and-control were removed, by, for example, having residents pay, at least in part, instead of being paid, for their residencies, the market would ultimately provide for as many of them as would be economic, in the specialities that would pay for them.

And what is the best solution to a shortage of clinical teaching faculty? The market. There is ultimately a market clearing price (i.e. wage) that would supply however many such faculty as are needed.
3.12.2006 4:52pm
JLR (mail) (www):
Mr. Hayden, thank you for your response.

I should issue a point of clarification. Based on the (admittedly incomplete) knowledge that I have of the situation, the most salient problem is not "shortage of clinical faculty."

Rather, the most salient problem is a shortage of quality clinical faculty. Med students and residents want to place in good rotations/good departments. If a med student ends up with a mediocre-to-lousy clinical faculty member, or in a mediocre-to-lousy department, it will mean less effective hands-on training.

Moreover, medical schools cannot simply "produce infrastructure." The "infrastructure" we are talking about consists of hospitals. Many medical schools have only one or two main hospitals that med students are placed in. Furthermore, only teaching hospitals are built to have residency and fellowship programs (other types of hospitals may have residents or fellows, but not in a systematic way).

It is difficult to produce hospitals for the sole purpose of training physicians if no patients exist to go to those hospitals. Moreover, the bottlenecks we're talking about can't be solved simply by the market. Quality, affordable clinical faculty do not just materialize in a market environment, like quality, affordable soap. In that sense clinical faculty are like sports players -- just as there are a limited number of people who can hit home runs, there are a limited number of people who are simultaneously capable physicians and capable teachers.

Also, certain residency programs (like ophthalmology, dermatology, and orthopedic surgery) are in very high demand, often due to their preferability for physicians vis-a-vis work hours and workstyle. If there were no command and control system, specialties like those I mentioned above would be overstocked with applicants, while specialties such as rheumatology or infectious disease (which require a fellowship) might be understaffed. Med students' demand for specialties does not always correlate with actual patient demand for said specialties. Market failure could very well occur.

Markets cannot by themselves produce a better quality of physician. The quality of physician is based not just on the quality of teaching, but inherent qualities of intellect and personality (i.e., a "bedside manner"). No matter how much training a med student/resident/fellow receives to become a physician, that physician-to-be cannot be trained to become a teacher if that person lacks the desire or the skills to become a teacher.

Markets generally are vastly superior to command-and-control systems. Markets solve the systems of simultaneous equations that comprise an economy. And yes, perhaps your claim is accurate: that if markets were there from the beginning, markets would be the best way to take care of medical schools.

But it is my contention that we can't unring the bell.

To have three medical students to every clinical faculty member is not acceptable. And to convert clinicians who are not at teaching hospitals into clinical faculty will be to force job descriptions onto physicians who would be unwilling and perhaps even unable to oversee med students/residents/fellows.

I hope the above comments weren't too strident; it is simply that I am passionate on this issue. It is my contention that instituting a pure market solution to the problem of physician shortages will create more problems that it will solve.

Thanks again Mr. Hayden for your comments.
3.12.2006 5:29pm
JLR (mail) (www):
Minor clarifications to my 3.12.06 5:29 pm post:

"It is difficult to produce hospitals for the sole purpose of training physicians if no patients exist to go to those hospitals" should really read "It is difficult to produce hospitals for the sole purpose of training physicians if no patients want to go to those hospitals."

There could be cases in which the raw number of patients might possibly be there to support hospitals created independently of patient demand (e.g., there could be people who should be patients who aren't currently being seen by physicians). But patients may not either (a) want to go to said newly-created hospitals that exist for the sole purpose of physician training because there are better hospitals they would rather go to, or (b) be able to go to said hospitals because those hospitals may not have the specific specialists that they need for their medical conditions.

Also, I should clarify that demand for rheumatology as a specialty is on the rise because the population is aging, and consequently the number of arthritis cases in the population is rising. Nevertheless, specialties such as dermatology, ophthalmology, and orthopedic surgery are in very high demand for placements because of work hours and workstyle -- the high demand to be trained for such specialties does not correlate with patient demand for said specialties.

Thanks again.
3.12.2006 6:02pm