A common theme to many of my posts here on The Almost Doctor’s Channel is the idea that we are at a point of great change in the medical field. I’ve covered such topics as how our healthcare system falls behind that of other countries, how the match can be improved, and how we can improve science literacy. Another area of my interest (and one that is readily apparent to those of us who are currently in medical school) is the design of medical training – notably its excessive length.
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Currently, after four years of undergraduate education, one must complete four years as a medical student followed by three to six years as a resident before being able to independently practice medicine. If no gap years are taken, this puts a person at 29 to 32 years of age when they are first able to contribute to the physician workforce – or even older if their specialty requires further fellowship training. If they decide to go into medicine later or circumstances prolong their education, this pushes them back even more. Because of this, some are hoping to shorten medical education.
As we look to shaping the future of medical education, though, it is important to note that this excessive length is a modern phenomenon, one that arises out of a desire to bring regulation and excellence to the profession. In the early 1900s, the Carnegie Foundation recognized the need to improve health care and enlisted an educator, Abraham Flexner, to survey the quality of medical schools and make suggestions for improvement. As Flexner wrote in 1910, “it is too obvious that if the sick are to reap the full benefit of recent progress in medicine, a more uniformly arduous and expensive medical education is demanded.”
Over the past century, this evaluation has guided medical training as it has become increasingly longer, a trend that cannot be sustained. This leaves us asking the question “How much medical education is necessary?” which can perhaps best be answered by first understanding how medical education has evolved into what we know today.
The Flexner Report
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Flexner’s evaluation was formed in the context of medical education in the earlier days of our country. As he explained, medical training in America began as a pure apprenticeship where a youth observed a practitioner, assisted with errands, and by the end was able to take part in the practice of medicine. This gave way to more formal education as some ventured to Europe to learn in a more didactic setting and brought this style of teaching back to the United States. While the first medical school arose in 1765 at the College of Philadelphia, informal classes in medicine in the US date back as far as 1750.
The first medical schools were associated with institutes of learning, but soon many freestanding, for-profit medical schools were formed as well. As the country expanded and people saw the financial gains of providing medical education, more and more of these for-profit schools popped up. In fact, between 1810 and 1910 more than four hundred and forty-seven medical schools were produced in the United States and Canada though many were short lived. With no state boards, the school diploma was sufficient for independent practice, and much unlike our competitive modern medical training, Flexner explained that “no applicant for instruction who could pay his fees or sign his note was turned down.” At some schools, after just sixteen to twenty weeks of education, these students were then set free to practice medicine.
This system resulted in a surplus of poorly trained physicians, which concerned the Carnegie Foundation and thus they reached out to Flexner. As a non-clinician, Flexner created his plan for medical education, the Flexner Report, from an educator standpoint, viewing advancement of science as the utmost responsibility of the physician. As he said of the time, “Progress in chemical, biological, and physical science was increasing the physician’s resources, both diagnostic and remedial. Medicine, hitherto empirical, was beginning to develop a scientific basis and method. The medical schools had thus a different function to perform.”
Reflecting on the Flexner report 100 years later, Thomas Duffy, M.D. said as a result “doctors had become neutered technicians with patients in the service of science rather than science in the service of patients.” He cited events such as the Tuskegee experiments and the Henrietta Lacks tissue culture incident. Flexner’s contemporaries had expressed this view as well. William Osler, for one, had warned “the ideals of medicine would change as ‘teacher and student chased each other down the fascinating road of research, forgetful of those wider interests to which a hospital must minister.’”
Nonetheless, the Flexner report made a remarkable impact on medical education. Physicians now receive at least six if not eight years of post-secondary education in a university setting. Medical training is now grounded in human physiology and biochemistry and follows the scientific method. Average physician quality has skyrocketed. Medical schools have become regulated. Ultimately, medicine has become a highly paid and well-respected profession, and its discoveries have drastically improved the lives of all human beings.
Beyond the Flexner Report
Flexner’s report made medical school four years in length, which was just the start to our extended medical training – internships and residencies as we know them did not exist in early last century. As Alexandra Minna Stern, PhD and Howard Markel, MD, PhD wrote in a 2004 article, “It was not until the dawn of the 20th century, with the rise of aseptic techniques, improved means of managing acute surgical diseases, and new diagnostic technologies, such as the X-ray machine, that the hospital became a place to be cured rather than a warehouse for the dying.” This resulted in a greater flux of patients to care for and a larger need for physicians to staff hospitals and clinics. It also coincided with more medical graduates wanting first-rate training in these hospitals and the further specialization of doctors. Thus during the period of World War I, internships and residencies became overseen by newly established accreditation boards as the vehicle for uniform training of all medical students.
Flickr | John Bosko
Over the years, residency positions grew exponentially – from 5,796 in 1940 to 46,258 in 1970 and approximately 110,000 today – as residency became the only accepted route to board-certified specilialization. While post-graduate training has followed the general educational trend of increasing in length, it has faced some restrictions in the past. In the 1970s, a yearlong internship that was required before residency became no longer required. Additionally, regulation in 2003 put limits to the hours a resident could work. Despite these limitations, residency has made medical training today approximately twice as long as it was a century ago.
The length of medical education has been criticized for many reasons. For the sake of the students, medical school incurs an excessive amount of debt with the average debt in 2013 being nearly $170,000 according to the American Association of Medical Colleges (AAMC). For the sake of the public as well, some have written that specialists are too old, too smart, and too expensive when they finish training, and as Olle ten Cate, PhD explains, “medical trainees may be wasting time at an age when they are supposedly at the top of their physical and mental abilities.” By accelerating advancement to independent practice, some have also suggested that we would be able to mitigate the physician shortage. Because of this, many are looking to shorten the length of medical education.
Despite the arguments for shortening medical training, there is still a tradition that relates quality to the length of training. Therefore, if medical training is shortened, it must be done in a way to maintain its quality in a shorter length of time while bringing more focus back to the patient in addition to scientific advancement. Additionally, while many agree that medical training should be shortened, there are many different opinions on how it should be done. Shortening undergraduate education, medical school, and residency have all been suggested as possible areas for cuts with the following reasoning
Undergraduate: Almost Doc’s own Skeptical Scalpel, MD wrote on kevinmd.com that a bachelor’s degree is not necessary for medical students. He explains that some medical schools have accelerated programs that combine BS and MD degrees in six or seven years, and doctors from these programs have been shown to have indistinguishable performance compared to traditional eight-year graduates. Shortening undergraduate education will not increase the number of graduating physicians each year, but it will make it possible for them to practice sooner.
Medical School: Stephen Abramson, M.D. made the argument in a NEJM article that by shortening medical school, students would be able to save tuition and also gain more earnings from entering the workforce earlier. He cited a different accelerated medical school program – the three year M.D. This program eliminates the fourth year of medical school, which has been traditionally been spent largely applying for residencies and visiting programs all over the country. Some schools have already incorporated the three-year M.D. while many more are in discussions.
Skeptical Scalpel criticized this option by saying that “There is way too much to learn in 3 years.” He also said, “the amount of time needed for students to choose their specialties and interview at 15 or more different residency programs could not possibly be squeezed into the third year of a three-year program.”
Residency
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Michael E. Whitcomb, M.D. raised a final opinion in Academic Medicine that it is not undergraduate or medical school that should be shortened but residency. His opinion is based not only on the physician shortage but also the limited funding for residency positions, a topic I have previously discussed. He says, “Shortening the length of training will not in and of itself guarantee that physician supply will increase to the level needed, but decreasing the length of training will make it possible to train many more residents in core specialties without increasing the aggregate amount that Medicare currently spends on GME.” By core specialties, he means those such as internal medicine, pediatrics, and general surgery, which are also those that are experiencing the most drastic physician shortage.
Nearly 100 years after Flexner’s original report, The Carnegie Foundation again reached out to educators to survey the state of medical education. This report was published in 2010 and recommended four goals for medical education: standardization of learning outcomes and individualization of the learning process, integration of formal knowledge and clinical experience, development of habits of inquiry and innovation, and focus on professional identity formation. According to a summary, the authors say, “As the challenges proliferate, a new vision is needed to drive medical education to the next level of excellence. The future demands new approaches to shaping the minds, hands, and hearts of physicians.”
How would you change our medical education system? Feel free to keep the conversation going below in the comments!
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