Friday, February 8, 2013

Creating more family doctors: should we shorten medical school? How?

At the recently-completed Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education, held in San Antonio, one of the big areas of discussion was the shortening of the medical school experience to 3 years for students planning to enter family medicine. Steven Berk, Dean of the Texas Tech University School of Medicine, and Betsy Goebel Jones from the Department of Family Medicine, described the Lubbock medical school’s recently-instituted program in a plenary presentation, and a later seminar featured presenters from several other schools which have instituted or are planning such tracks, including the Savannah campus of Mercer University School of Medicine, Medical College of Wisconsin, as well as Texas Tech. The goal of such tracks is to increase the number of students choosing to enter family medicine by eliminating one year of school, and thus tuition; these schools believe that this financial incentive at least helps a little to offset the lower income that accrues to family physicians compared to other specialists. To the extent that these students then enter family medicine residencies at those same schools, it also decreases uncertainty for both the student and the program.

The most direct forebears of these programs were in the 1990s, at some of the same schools. They offered an “accelerated track” for family medicine, in which students began their first year of FM residency while completing their final year of medical school, getting the MD degree after that year. While initially approved by the American Board of Family Medicine as a pilot, these programs were closed when the decision was made by the body that accredits residencies that one could not get credit for residency training until after receiving the MD degree. This latest effort gets around this by granting the MD degree after 3 years, mainly by compressing the final year of medical school; in most schools the fourth year is already largely used for electives.

Not all accelerated MD programs are about increasing the number of primary care, or certainly family medicine, physicians. A program at the NYU School of Medicine, which remains one of the few US medical schools to not even have a Family Medicine department, was featured in the New York Times "N.Y.U. and Other Medical Schools Offer Shorter Course in Training, for Less Tuition" by Anemona Harticollis, December 24, 2012. While the Texas Tech and Mercer-Savannah programs are also mentioned, NYU’s program is clearly not about producing more of the primary care physicians that the US needs, as this is not something NYU seems to care about at all. As of now all of these programs are “tracks”, rather than for all students; they recruit “high-performing” students who can finish the traditional curriculum in a shorter time.

Interestingly, these current programs do not focus on shortening the amount of time or changing the content of the first two years of medical school, the “basic science” years. This struck me as odd, because when I went to medical school (Loyola-Stritch) in the mid-1970s, it was precisely this component that was shortened (to 12 months, with 2 full years of clinical training). Loyola was far from the only school to do so during that period; my current school, the University of Kansas and many others did so; according to an article by Walling and Merando in Academic Medicine[1] “…By 1973, 27% of U.S. schools offered compressed three year curricula.”  For most, this was not a “track” but was the curriculum for all students. The primary method of shortening the curriculum was abbreviating the time spent in basic science, although the amount varied (at KU it was 15 months). It is thus, to me, surprising that in the current efforts to decrease the length of training very little attention has been paid to shortening the basic sciences. Walling and Merando note that “Although educational outcomes were very similar for three-year and four-year curricula, most schools subsequently reinstated the fourth year to provide students with a broader clinical experience.” I don’t completely buy that; at least at Loyola, the clinical experience was not shortened during its 3-year curriculum. It surprised me in talking to people at the conference that so few even knew about these “experiments” from the 1970s.

My guess is that the current efforts focus on reducing the 4th year rather than the first two years because of politics. No one “owns” the 4th year, but the first two years are “owned” by the basic sciences in most medical schools, and by a strong advocacy constituency in the Association of American Medical Colleges (AAMC), the National Board of Medical Examiners (NBME) which offers the US Medical Licensing Examinations (USMLE) and other groups. They have strongly resisted efforts to decrease the time spent on basic science teaching in medical schools individually, as well as nationally. An effort by the NBME to combine the 3 “steps” of the USMLE into two was seen as “elimination of Step 1” and generated huge opposition from the basic science community; the change has been put on hold for several years.

While the need for students to pass “Step 1” is often used as the ultimate reason to not cut back biologic science curricular time, the fact is that students can pass this test with significantly pared-down content. Hopefully, however, there is a better reason to teach basic sciences. That would be that learning the concepts that are important for everyone training to be a doctor to know rather than forcing the memorization of details that are irrelevant, can be looked up, or are likely to change regularly. It means both subjecting the content of curriculum to the this test of relevance, and increasing the breadth of disciplines included as “basic” to include social sciences such as psychology, anthropology, sociology, epidemiology. The teaching -- and testing -- of all this material should focus on understanding concepts, solving problems, and knowing where to look up detailed facts, rather than memorization.
We do need more primary care doctors, and more family physicians to meet the health needs of the American people. We need to do everything possible to make this happen, and addressing financial incentives is a big part of it. Another plenary presentation at the meeting from STFM President Jerry Kruse addressed the successful efforts in Canada to increase the number of primary care doctors (in that country, all family physicians); the key element is decreasing the ratio between primary care and specialist income, and the effective ratio is between 80-85%. There are also good arguments for decreasing the cost of medical education, and perhaps shortening medical school is one method of doing so, especially if it can be done without sacrificing important training; it certainly needs to be relevant training.

But these efforts – to increase the primary care workforce and to consider the appropriate length of medical education – are different. They may complement each other, or may not. The strategies that we employ should be based on their effectiveness at achieving our goals, and for that to happen we need to be clear on what those goals are.  Piecemeal approaches may ultimately work, but they are not the most efficient ways of approaching the problem.

Of course, in terms of health insurance reform, piecemeal is the way we have chosen to go rather than a comprehensive national health program such as Medicare for All; why would we expect a more rational approach to improving medical education?

[1] Walling A, Merando A, “The Fourth Year of Medical Education: A Literature Review”, Acad Med  November 2010  85(11): 1698-1704.


Josh Freeman said...

Posted for Dr. Daniel Swagerty:
This posting was a very nice review of a very important issue we must confront in US medical education - increasing the primary care workforce. For me, it would make sense to shorten medical school for all students to 3 years, even if some residencies have to be lengthened by another year. The 3 year period could be evenly split between basic sciences and clinical clerkships. However, keeping basic sciences as long as 18 months would have to include much more emphasis on the social basis of medicine and service-based learning.

Then there is the issue of undergraduate education. While a well -rounded education should be required for our entering students and may require 4 years to complete, many of our students are coming to us with very deep course work in a narrow area of science - chemistry , biology, biochemistry, neurosciences, etc - without much understanding of the broader context and relationships of science, society and humans.

There are real merits to considering a track of 3 years each for undergraduate , medical school and residency training for our primary care physicians. This approach could result in a significant increase in a well trained and versatile primary care provider - the family physician. This approach may very well also have the added benefit of capturing the interest of those currently being splintered into the separate , but very similar, tracks of family medicine, general internal medicine, general pediatrics, and advance practice nurses. As a nation, we must focus our educational and health care resources towards developing a unified and well supported cadre of primary care providers in much larger numbers. For those providers interested in addtional and more focused primary care expertise, an addtional year or two of postgraduate training could then be spent developing in areas such as pediatrics, womens health, geriatrics, palliative care, long term care medicine, hospital medicine, and public health - to name just a few areas of real need. It is very clear that we need less tweeking and more revoluntionary action in medical education. Something to think about, then act on !

Bob Bowman said...

Here are the Standard Primary Care Years per graduate for the potential sources of family medicine and the number of annual graduates each class year 2020 to 2050 for sufficient sole source primary care for the entire nation (over 80 per 100,000 for 400 million people).

8 - 9 years of prep, med school, and 3 year FM residency requires 14,000 annual graduates at a post high school cost of 12 billion dollars a year for sufficient primary care 2050 and beyond.

Accelerated FM is a 4:3:3 for 26 Standard Primary Care Years in a career and 15,400 graduates at about 16 billion dollars.

Standard FM is a 4:4:3 for 25 Standard Primary Care Years requiring 16,000 annual graduates and 19 billion dollars.

The 4 years for FM for GME would result in only 22.8 Standard Primary Care Years and would require 17500 annual graduates at a cost of 24.5 billion dollars.

Of course you could remain with the current 6 sources with only 30% primary care result for 21 billion for half enough primary care.

Solutions specific to primary care recovery are most years of practice and lower cost per graduates. These are also the solutions most likely to remain distributed and in family practice across entire careers - by design.

If you want to double the cost for primary care recovery, then jump on the bandwagon for longer and more academic training.

If you want to recover primary care, then support preparation, medical school, and FM residency integrated with health access sites right out of communities and high schools - for optimal primary care and primary care where needed.

The integrated approach also selects and trains for team care, HIT, quality, and self assessment qualities - before entry to medical school and specific to health access.

It is a dollars and sense approach - fewer dollars for more primary care that distributes better.

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