Saturday, November 2, 2013

Should Medical School last 3 years? If so, which 3?

Displaying as_seen_woz_chart_review (1).jpgAs we look at how to increase the number, and percent, of students entering primary care residency programs, it is interesting to see how some schools have creatively tried to address the problem. Texas Tech University Medical School and Mercer University Medical School’s Savannah campus have begun to offer MD degrees in 3 years to a select group of students who are both high performers and planning on Family Medicine careers, thus decreasing their indebtedness (one less year of school to pay for) and getting them into family medicine residencies, and several other schools are considering the same. They do this by essentially eliminating the fourth year of medical school. This is the subject of a piece by surgeon Pauline Chen, “Should medical school last just 3 years?” in the New York Times. She discusses different perspectives on the fourth year, previous experiences with reducing the length of medical school training, and two ‘point-counterpoint’ essays on the topic in the New England Journal of Medicine.

Chen addresses prior efforts to shorten medical school, including the most recent precursor of this current one. Specifically aimed at increasing the number of highly-qualified students entering Family Medicine residencies, it was implemented in several in the 1990s, and allowed students to effectively combine their 4th year of medical school with their first year of family medicine residency, thus completing both in 6 years. The programs were successful by all criteria. Students did well on exams and were able to save a year of tuition money, and medical schools were able to retain some of their best students into family medicine. Of course, therefore, the programs were stopped. In this case the villain was the Accreditation Council for Graduate Medical Education, which decreed that the fact that because students did not have their MD when they started residency training (it was granted after the first year, a combined 4th year of medical school and internship) they were ineligible for residency training. Thus this newest iteration offers the MD degree after three years.

An older effort to shorten medical school is also mentioned, one with which I have personal experience. In the 1970s ”as many as 33 medical schools began offering a three-year M.D. option to address the impending physicians shortages of the time.” One of those was Loyola-Stritch School of Medicine, in which the only curriculum was 3 years. In 1973, I was in the second class entering that program. We spent 12 months in ‘basic science’, pretty much just in classes in the mornings, and then two full years in clinical training. Chen writes that “While the three-year students did as well or better on tests as their four-year counterparts, the vast majority, if offered a choice, would have chosen the traditional four-year route instead.” I have no idea where she gets this impression; it is certainly not at all my memory. Our friends across town at the University of Illinois went to school for two years of basic science, 8 hours a day to our 4. We did not envy that. As Chen notes, we did just as well on our exams, and saved a year’s tuition, and I daresay no one could tell the difference in the quality of the physicians graduating between the two schools, when they entered residency in 1976 or today after 37 years of practice. Again, it was all good.

And, again, it was stopped. Why? Of course, the experiment only led to one additional class of physicians being produced (after that, it was still one class per year) so that benefit expired, but what about the other benefits that I have cited? Why wasn’t the program continued? Chen hits the nail on the head in her next paragraph: “The most vocal critics were the faculty who, under enormous constraints themselves to compress their lessons, found their students under too much pressure to understand fully all the requisite materials or to make thoughtful career decisions.” In particular, the basic science faculty who taught the first two-years-now-compressed-into-one of school. The fact that students did just fine on USMLE Step 1 and became good doctors was apparently insufficient to convince them. They made arguments like the one above, shifting the problem from to the students (“they” were under too much pressure) rather than that the faculty felt the pressure. I can’t remember anyone wishing they had another year to spend in basic science lectures.

The truth is that there is no magic amount of basic science time educational time needed to become a doctor. The amount of time needed is the amount necessary to either: (1) learn enough to pass USMLE 1, a fine utilitarian standard, or (2) learn the key pieces of basic science information that every physician needs to know in order to be able to practice quality medicine. If there are some basic science faculty might bridle at the idea of #1 (“Teach to the test? Moi?”), trying to identify what comprises #2 is a lot of work. It is easier to teach what we have always taught, what the instructors know about. If the reason for more time were the amount of basic science knowledge, then what required two years 35 years ago would require 10 or more years to teach now, because so much more is known. That is not feasible. The right answer is #2, but getting folks to do it is hard.

Chen quotes Dr. Stanley Goldfarb, lead author of the perspective piece against three-year programs as saying “You can’t pretend to have a great educational experience without spending time on the educational experience,”  which is of course true but begs the question of what those experiences should be. If we are going to decrease the length of time students are in medical school, it makes much more sense to reduce the amount of time spent in learning basic science factoids that most will forget after USMLE 1 (reasonable enough, since they will never need most of that information again) and focus on adult learning by teaching that information that all physicians do need to know. This effort requires clinicians having major involvement in the decision about what that is. It makes much less sense to remove one of the years of clinical training; what should be done is that training should be augmented, become less about vacations and “audition clerkships” and more about learning.  Why this is unlikely to happen, of course, has nothing to do with educational theory or the quality of physicians produced and everything to do with medical school politics. There is no constituency on the faculty for the fourth year, and a strong basic science faculty constituency for the first two.

Yes, we need more primary care doctors, lots of them, and we may need more doctors altogether, to help meet the health needs of the American people, and we need them soon. Data from the Robert Graham Center of the American Academy of Family Physicians (AAFP)[1] (attached figure) show the projected increase in need, including the one-time bump from the ACA, which will bring a large number of people who have not had access into care, and the longer-term need from population growth and aging. Programs that increase the number of primary care doctors (like the 6-year family medicine programs of the 1990s) are good. Programs that decrease the number of years by reducing basic science courses rather than clinical times obviously make more sense from the point of view of having well-trained doctors. (Programs like the 3-year option at NYU which is not even geared to training more primary care are, from this point of view, irrelevant.) We need to have these not be pilots, but scaled up to produce more clinically well trained primary care doctors.

And we need to do it soon. Medical school turf battles should not be the determinant of America’s health.

[1] Petterson SM, et al., “Projecting US Primary Care Physician Workforce Needs: 2010-2025”, doi: 10.1370/afm.1431 Ann Fam Med November/December 2012 vol. 10 no. 6 503-509

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