Reflection of values

The School of Medicine pledges $100 million to offset tuition through scholarships and revise the curriculum

A Q&A with Eva Aagaard, MD, and Valerie Ratts, MD

Matt Miller
Valerie Ratts, MD, left, and Eva Aagaard, MD

On a crisp autumn Saturday two years ago, the newly appointed senior associate dean for education began getting ready for an important finance meeting with the medical school’s senior leaders. That’s when a crazy idea struck her.

“I was thinking about ways to reduce medical school debt and, on a broader level, my overall purpose here, when it suddenly occurred to me that it would be a good idea to become a free medical school,” recalled Eva Aagaard, MD, also the Carol B. and Jerome T. Loeb Professor of Medical Education. “I seriously thought I would be laughed out of the board room.”

But David H. Perlmutter, MD, executive vice chancellor for medical affairs and the George and Carol Bauer Dean of the School of Medicine, didn’t laugh. Neither did Richard Stanton, associate vice chancellor and associate dean for administration and finance, nor did Valerie S. Ratts, MD, associate dean for admissions and a professor of obstetrics and gynecology.

In fact, Ratts found herself nodding in agreement. The medical student admissions office was thinking along similar lines.

Dozens of meetings later, the crazy idea evolved into a serious scholarship program, and its announcement made headlines last April. The School of Medicine would commit $100 million to scholarship and education over the next decade — allowing as many as half of its medical students to attend tuition-free and many others to receive partial support. The funding also underpins curriculum revision efforts.

Washington University is one of a growing number of medical schools instituting steep tuition-reduction programs. The program took effect in the 2019-20 academic year.

How did the conversation about free and reduced tuition evolve?

Aagaard: It grew out of a real concern about the amount of debt medical students were acquiring, and how that is influencing career choices, and, specifically, how educational costs might be pushing people out of careers in academic medicine.

What I love about my job is that you can have a crazy idea and people here won’t laugh. Instead, they’ll ask about the reasoning behind the idea.

We went through many iterations about what we were trying to accomplish. We want to minimize debt and increase people’s freedom to pursue the medical specialties they’re most passionate about, instead of selecting the ones that will pay off debt more quickly. We want to train academic physicians — those who work at teaching hospitals and instruct medical trainees, those who pursue research, and those who lead improvements in the health-care system. One of the biggest barriers to pursuing academic medicine is leaner earnings compared with private practices.

All of the qualities dovetail with our new curriculum’s emphasis on academic medicine and community health care. The new curriculum will debut in the 2020-21 school year.

Ratts: Dean Perlmutter and Rick Stanton recognized that if we are going to remain a top-10 medical school, we had to address medical school debt. The vast majority of our students, if not 100 percent, factor in finances when selecting medical schools. We don’t want money to be a reason why a highly qualified student selects another medical school.

It always has been a top priority to graduate physicians with as little debt as possible. In four of the past five years, the School of Medicine has ranked second-lowest nationally in average medical school debt. This new scholarship program expands upon these existing efforts to reduce medical student debt.

Where does the money come from to support the $100 million investment?

Aagaard: The funding for the scholarship program and revised curriculum comes primarily from the School of Medicine, through new funding from its departments, and the university’s affiliated training hospitals, Barnes-Jewish Hospital and St. Louis Children’s Hospital. It comes from the operational funds of each entity and represents a commitment to support our academic mission.

It’s different than the other medical schools that procured funding from a major donor. It’s a statement about the values of the School of Medicine and its partner hospitals. That’s not to say we don’t want donors to commit to it, because we do.

How is this scholarship program sustainable in years to come?

Aagaard: Dean Perlmutter is committed to it over a 10-year period without knowing what the program’s outcomes are. A decade provides an idea of the program’s impact. We don’t feel like we can judge its impact in a shorter time frame. But we will examine it closely.

We’ll look at the students, both those who receive full or partial scholarships and those who do not. How does it influence student well-being? How does it affect career choices?

How have alumni reacted?

Ratts: Alumni cheered when we announced it at events. Medical student debt is a primary concern among alumni. Many of them have children pursuing medical careers who are facing extreme debt. They also mentor a huge number of medical students all around the country, and they feel strongly that we need to do something.

What has been the student response?

Aagaard: The incoming students are thrilled. The existing students have had a mixed response. There were a number of students who appreciate that the school is investing in students and addressing this problem. A number of students were personally disappointed but understood. And then a group of students felt like we didn’t factor their debt into the equation, and we’ve been looking at that.

“Our intention is to recruit the best and brightest students who are passionate about improving health care in the community and across the globe.” – Valerie Ratts, MD

Note that we just announced a one-time $3 million investment in current students to reduce debt. The program will provide scholarships to those students who are expected to graduate with greater than $150,000 debt and who have been identified to have financial need based on FAFSA.

How do you hope the scholarship program will affect student diversity?

Ratts: The program is being used to recruit the entire medical school class. A scholarship committee will award scholarships based on several factors, including financial need, merit or a combination of the two.

Our intention is to recruit the best and brightest students who are passionate about improving health care in the community and across the globe. We want to attract students who represent a diversity of racial, ethnic and socioeconomic status.

But we also value diversity of experience, for instance, non-traditional medical students. We want people who we think have the potential to change the face of medicine.

The scholarship program allocates $25 million to curriculum revision. How does tuition fit into the broader picture?

Aagaard: Curriculum renewal allows us to create a state-of-the-art curriculum that not only trains outstanding physicians, but also trains people in the skills they need to pursue their passions in science, education and advocacy.

We already have an outstanding curriculum in science. We are one of the best schools in the country at training physician-scientists in basic science, translational science and clinical science. We’re building on that, thinking about other kinds of academic physicians, such as outstanding clinicians, physician-educators and physician-advocates.

The new curriculum encourages us to do creative things concerning community engagement, which is something that we feel has been lacking in our current curriculum. Community medicine and outreach have been considered more extracurricular activities. We plan to embed it in the curriculum to give it the importance it deserves, which allows us to do a better, more consistent job of teaching about social determinants of health and other critical topics. This will impact positively the kinds of students who may choose to come here.

Ratts: Curriculum renewal is looking at how we’re going to educate the physician of the future. How they will practice medicine is going to be very different.

Previously, a medical student went to school and did two years of basic sciences. And why did they do that? To learn all the basic science you’d ever need to be a physician. That model doesn’t work anymore.

All the information we need as physicians is truly at our fingertips, and we have to learn how to better access and apply it. The field’s changing every day, and the knowledge is exploding. We’re thinking about what students need to be successful 20, 30, 40 and 50 years from now. What is that skill set that will make them successful for what’s coming in the future? And nobody completely knows, but we have ideas and we need to prepare students.

Aagaard: At no time in the past has there ever been so much knowledge accumulating so quickly. Physicians need to know how to integrate the technology into the medical practice. A big part of the physician’s job has transitioned to translator of that information. This involves helping them to curate information sources, understand how the information applies to them and their unique situation, as well as helping to determine decisions that are right for them based on their values.

We’ve moved from a much more paternalistic model of care to a much more engaged, patient-centered one. That is a big part of what’s different now, and it’s a whole skill set medical trainees need to learn.

Interview condensed and edited by Kristina Sauerwein, senior medical sciences writer.

Published in the Autumn 2019 issue