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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