The Duke School of Medicine placed third in research in this year's annual U.S. News and World Report graduate school rankings published three weeks ago. But in the same issue of the magazine, Duke ranked 21st in primary care.
"[These rankings] do not mean one area is better than the other, but I think there are differences [in the rankings] because there are differences in the two programs. How accurate they are, I don't know, but few schools would excel at both ends of the spectrum," said Dr. Dennis Clements, medical director of primary care for the Private Diagnostic Clinic and vice-chair of the Department of Pediatrics.
Harvard Medical School and Johns Hopkins Medical School were named one and two, respectively, ahead of Duke this year in research. The magazine listed the medical schools of the University of Washington, Oregon Health Sciences University and the University of New Mexico as the top three primary care schools.
The research and primary care rankings were based on a weighted average of seven indicators, six of which were common to both models. These six categories included two surveys of reputation, student selectivity, faculty resources, overall rank and "specialty rankings." To determine research rankings, U.S. News and World Report used research activity as the seventh criteria. In contrast, the criteria used to determine primary care rankings was the rate of students who entered primary care specialties over a three-year period.
Some are skeptical of the ranking's methodology. For instance, the primary-care rate reflects the percentage of students who do a primary care-related residency. "The percentages used [to rank] primary care may be spurious since just because someone does a pediatric residency does not necessarily mean they will go into pediatrics," explained Kay Singer, associate dean in Trinity College and director of the Health Professions Advising Center. "Someone who is never intending to go into primary care may have to do a primary care residency in order to go into a subspecialty. It may appear from the statistics that a student is going into primary care when they have no intention of entering it."
Using a school's primary care rate as a ranking criterion may also be skewed depending on a school's primary goal. For example, the Brody School of Medicine at East Carolina University, ranked 17th in primary care, operates with the specific mission of training people to go into primary care. "[Brody] was created with a legislatively-mandated mission to train physicians and [attention] swung our way when primary care in medicine became a national hot topic in the mid-'90s," said Dr. James Peden, Brody's associate dean of Admissions.
Although Peden did not know what rate of students actually went into primary care practice, the percentages of students doing primary care residencies has consistently hovered around 60 percent. The percentage of Duke students doing primary care residencies between 1998 and 2000 was 44.8.
Ranking differences between research and primary care are not unique to Duke alone--Harvard, Johns Hopkins and University of Pennsylvania are all among top-tier research medical institutions that do not have comparable rankings in primary care. "These schools have all been established, financed and recruited for historically on their research missions, and it is only recently that primary care has become a priority," said Clements.
And while Duke has a large number of faculty devoted to primary care, it simply has far more specialists. "Duke has always been a research institution.... I wouldn't say that the ratings reflect a difference in the quality of our primary care, or of their research and educational programs, but the ratings do reflect the difference in size of the primary-care and subspecialty program," said Lloyd Michener, Chair of the Department of Community and Family Medicine.
Although U.S. News and World Report has used a dual ranking in the past, it originally did not score medical schools in primary care.
"We changed the rankings because readers were criticizing us for making the tacit statement that the best medical education can only come from the research-intensive institutions," said Gayle Garrett, project director of America's Best Graduate Schools 2002.
Despite the rankings, few people believe dual rankings will affect future applicants to the School of Medicine. "Students tend to have a sense of what different schools focus their training on so those individuals who have a desire to practice primary care will self-selectively go to those schools," said Dr. Ralph Snyderman, chancellor of health affairs and interim dean of the medical school. "We tend to draw students nationally who want to come to Duke for its research, whereas schools involved in primary care have little clinical setting. There's a very different mindset between the two environments."
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