Friday, March 21, 2014

Should medical school be shortened to 3 years?

I say, "No." Here's why.

There is way too much to learn in 3 years. Unless medical education is radically changed, it will be impossible for students to memorize all the unnecessary stuff they still have to memorize, complete all their clerkships, and move onto the next phase—residency training.

I do not see how medical students can choose a career path before they have had experience with rotations in all of the major specialties. I have had numerous queries from students in four-year schools who do not know what they want to specialize in even by the first part of their fourth year.

Yes, the fourth year of medical school currently is not productive. However, 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.

Some have said that shortening medical school to three years would increase the number of doctors produced. That would be true for one year when schools would graduate two classes, the three-year and four-year groups. But after that year, the same number of students would graduate from school as did so when the length of time was four years.

By the way, that year with the double graduating classes would be difficult to manage because there is already a predicted shortage of residency positions by 2015. This is due to the federal government's cap on the funding of resident positions. Graduating more than 40,000 medical students at the same time when only about 25,000 residency slots are available would be chaotic.

Here's a better solution.

The length of time it takes to become a doctor could be shortened by simply not mandating that every medical student have a four-year undergraduate degree before starting medical school.

Who says that medical students need to have a bachelor's degree in anything? If for some reason that is still desired, students could attend college through the summers to pick up enough credits for a degree.

A few medical schools in the United States have had accelerated programs in place for many years. For example, a program jointly run by Penn State University and Jefferson Medical College graduates doctors with both BS and MD degrees in six or seven years. It's been around since 1964. A longitudinal study over 26 years showed that doctors who completed that accelerated program performed at a level indistinguishable from traditional eight-year graduates.

A recent compilation lists several colleges/medical schools (of 140 or so MD-granting medical schools in the US) with similar accelerated programs.

Several European countries use similar models and seem to have healthy citizens.

Shortening or accelerating the undergraduate experience would save a year or two of tuition expense, accomplish the desired saving of time, and not disrupt the four-year med school cycle.

Of course, this will not get any further than this blog because I am not a "good old boy" with any influence on those who run medical education.


Anonymous said...

As a fourth year medical student graduating this May, I could not agree more. I am sometimes flabbergasted that medical school remains only 4 years given the rate of medical discovery and growth in volume of material for each subsequent class to learn. Three years would be grossly inadequate to complete all the necessary coursework as well as the match process. The requirements have become so extensive that I was still taking required rotations through December of my fourth year right up until interview season, and taking electives throughout interview time. My classmates all had to do the same. I would sooner advocate for making medical school 5 years than making it 3. I agree that the preferable way to shorten the process as a whole is to accelerate undergraduate work; while I loved my four years as an undergraduate, I doubt that cutting it short would leave me any worse of now.

artiger said...

Scalpel, who says you're not a good ole' boy? I'll fight them.

Seriously, I agree with a good bit of that. The first two years of med school contained a lot of minutiae that I think was unnecessary, or at least could have been studied outside of a classroom (I'm talking about how it was in 1988 or so, it may be different now). Basic information is now so readily available. If med school were to be shortened, I'd eliminate part of the old basic science portion and leave the clinical part intact.

But I agree that the place to cut off time is undergrad. I was accepted to med school in my third year of college. I boned up on the sciences courses and left off a lot of the humanities and such, plus I pulled a couple of summers. So I don't have a bachelor's degree. Not surprisingly, I have yet to hear a patient ask me about it.

The only strong argument I can make for shortening med school would be for the costs that would be saved, as med school tends to be a lot more expensive than undergrad.

Anonymous said...

There are actually some medical schools in Canada that are three years long (McMaster University and the University of Calgary are the two that come to mind, although I think there are more). Apparently none of the content is cut, but rather accelerated. It seems to work, because McMaster is renowned for being one of the best med schools in Canada. Regardless, the four year model is the most common and generally more preferred.

Anonymous said...

I went to college and med school in Canada. The med schools accept students after 2nd year college, provided all the pre-req courses were completed. About half the entering class did have their bachelor's degrees already. Aside from the age difference and (maybe) social maturity, I couldn't really tell one group from another.

Skeptical Scalpel said...

Thanks to all four of you who commented. I wasn't aware of the situation in Canada, which seems to support my position. Also, thanks for reinforcing the idea that the place to cut is in the pre-med years.

Anonymous said...

I am a medical student in Belgium. My program is 7 years long with the first three years covering basic sciences, anatomy, many of the other pre-clinical requirements (physiology, microbiology and so forth). It was all presented with a very heavy emphasis on the actual clinical practice of medicine.

I am currently in the fourth year which is where we start covering the clinical subjects. The great thing about this system is that having covered a very large amount of the basics in the first three years, the clinical subjects fall very nicely into place and we are very quickly sent off on our clinical rotations (I just finished my first one). All in all in the last four years we have 36 months of rotations with responsibilities that gradually increase.

I have so far been very happy with it. The three focused pre-clinical years were great at laying a solid foundation upon which to build our clinical knowledge and the placement system allows us to gain a lot of experience in hospitals before deciding on a specialty.

I already have a hard time imagining how everything is crammed into 4 years in the US and from my perspective, the requirement for a bachelor's degree seems quite silly, especially with the extra financial burden that it places upon the students. Here this really isn't an issue as one year of university (medical or otherwise) costs 800 euros.

Anonymous said...

I should add that Canadian med schools are accepted on par with USA ones for residencies and state licensure. Canada is the 51st state, after all. :).

It is interesting how different countries approach higher education, including med school. I paid less than $2000 a year in Canada. It is prob up to $5000 or so by now, but it is still a much less than American schools. I believe that the UK, western Europe, Australia provides very good training at similar or lower charges. Obviously, the taxpayers in those countries are subsidizing the actual costs, but they have determined that having doctors and engineers and teachers is a social good, and will pay for it.

The American paradigm is different, and I don't see it changing.

Anonymous said...

nycom has an accelerated program for family medicine. you apply during 1st year, take some additional classes and you lose your summers but you are guaranteed a spot after your 3rd year.
you do all your 3rd year rotations - though shortened by a week and you get a couple of electives, then you do a subi in the place you'll be an intern in a few months.
i know its a funneling program but it does shave a year off the cost - not insignificant and all you have to do is pass your boards.
certainly a good option if you are already interested in fp

ayeekaz said...

I'm from South Africa. We have two medical tracks: the normal is to go straight into medical school after high school and do a six year degree. First 2 years are basic sciences, 2 years of integrated clinical theory and 2 years of practical rotations. The second is to get a different degree in anything and join in at year 3 (provided you have some science proficiency). I did the traditional way and now in my final year, I don't think the process is very good. A year spent exclusively on physics and chemistry was not worth it. Moreover, clinical rotations are far more useful than classroom learning. A good theoretical foundation is important; but the current model places too much focus on it.

Skeptical Scalpel said...

Thanks to the four people above for their excellent comments.

It's interesting to read how other countries do it. I don't see the American system changing either.

Regarding the funneling of students into family medicine by reducing the length of the process or tuition forgiveness has been tried before. One of my very first blog posts was a tongue-in-cheek look at it.

The situations in Belgium and South Africa are slightly different. I appreciate the fact that physics and chemistry aren't really to useful to clinicians.

Anonymous said...

This is a response to the above comment about 3 year Canadian schools. I went to med school in Canada. There are two 3 year programs in Canada. One of those schools has a great international reputation because of its excellent research programs. Their graduates are rumoured to make worse first year residents because they are not well prepared clinically. The ranking of a medical school means little when it comes to the clinical competence of its graduates.

Skeptical Scalpel said...

Interesting. I wonder if any other Canadian readers can comment on this?

artiger said...

Scalpel, this post dovetails nicely with your previous one about how screwed up the US system is.

Anonymous said...

I did my medicine internship in the 1000 bed (at that time) hospital an hour or so from the 3 year med school in Canada. We had plenty of their graduates, but the place was so big I have no idea how they fit clinically as a group. Certainly, as senior residents they were as good as any.

I agree that a med school's reputation primarily rests on its research.

The only prolonged downtime in med school is the 3 months between 1st and 2nd year. So the 3 year schools are cutting out 9 months of teaching. Are they mostly from the basic science or clinical side?

The extreme is that once upon a time there was at least one med school (University of Miami) that awards an MD after just 2 years to qualified PH.D's.

The guy I knew who did the 2 year MD got his PhD in engineering, and never practiced medicine after his MD. However, he was a pioneer in the field of intraop neuromonitorimg.

Skeptical Scalpel said...

Yes, it does mesh nicely with the screwed up system post.

I think it is very hard to rate a school. Even if you know 10 graduates, how can you tell about the hundreds of others? Having a big research program does not necessarily mean that the med students will be good clinicians.

I don't know what the 3-year med schools are cutting out. I hope it's basic sciences.

Hope said...

Fourth year could definitely be more productive. Besides the educational benefit of 4 years of medical school, however, I think there is something to be said for the maturity that the passage of time affords.

I've always been amazed by the concept of "crockpot" learning - you learn something, put it away, let it simmer subconsciously, and then when you come back to it, somehow, someway, the concepts are more accessible and understandable. It happens to me all the time, particularly with pattern-recognition and clinical decision-making. The brain works in an interesting way, processing and learning things even when you're not actively working at it. In addition, time allows for the acquisition of life experience and maturity. As a university and medical student, I did a number of volunteer jobs and rotations in England, where you're basically on an accelerated path starting at age 18 to learn medicine. Although the ultimate length of training works out to be the same at the states because post-graduate education is prolonged there, the age at which you have patient contact/care responsibilities is much younger than here.

I have to say there is something *not* insignificant about having someone who has a little more maturity and perspective working with patients. Even now, when I see PAs who just turned 22 running around the hospital taking care of patients and then giggling and texting on the sidelines, it makes me feel like even they are too young to deal with the gravity of the job. A lot changes between age 21 and 26. I think the length of medical school and the path to get there, actually does offer benefits in twofold: one, the opportunity for the brain to process and integrate detailed clinical concepts for more efficient application, and the time to mature into more of an adult who can navigate the emotional demands of doctoring with grace.

Anonymous said...

In Sydney, Australia, medical school used to be a 5 year undergraduate course, done straight out of high school. It was a bit too fast, so they made a 6 years. Now, it is a 4 year post graduate degree in most places, although a 5 year and also a 6 year undergraduate degree remains.

Speaking with one of my American attendings, who now works down here, who trained in the USA, the end product is similar. We have a longer residency /registrar/training period, which is better paid and less like slavery and choose our specialty much later. I cannot imagine who you can cram it into 3 years without biomedical sciences being a prerequisite. Maybe I am just old school.

The difficulty as always is choosing your candidates, and trying to guess which ones will be good doctors when they grow up. You would enjoy reading this guys writing:

Skeptical Scalpel said...

Hope, you make some good points. I don't think maturity suddenly happens one day. It's different for each individual.

Anon is right. The difficulty is in choosing your candidates.

Anonymous said...

Canadian here. Hope to be attending a 4 year school in the fall but interviewing at one of the 3 year schools next week (we find out our results in May)

To clarify--the 3 year schools don't have summers off (well they get a 2 week break, rather than 3 months). That's how they make up for the extra year. Clerkship starts in November of 2nd year, so students typically have 14 months of pre-clerkship by then.

The main disadvantage of attending a 3 year school in Canada is the lack of summers. If you want to match to a competitive specialty in a major city (ie, research-heavy institution), it's hard to have delved into research or some other project related to your specialty of interest during med school.

They try to keep the curriculum as flexible and light as possible so that students can participate in these types of activities during medical school.

In Canada, we don't write a standardized exam such as the USMLE Step 1 during medical school. Also, most schools follow a Pass/Fail system now (and class rank isn't really disclosed). There's no AOA (UofToronto *might* still have it but nobody seems to make a big deal out of it). Hence, the only way to distinguish yourself as an applicant is by making a good impression during electives, or participating in some sort of project during medical school.

The lack of summers to participate in that type of project in medical school is the main disadvantage of attending a 3 year med school in Toronto

Canadian pre-med said...

Minor correction, last sentence should read: "main disadvantage of attending a 3 year med school in *CANADA*". The University of Toronto is a 4 year medical school.

Skeptical Scalpel said...

Thanks for the info about Canadian schools. Good luck with your interviews.

Anonymous said...

why the rush?
the lack of planning on the part of us education does not constitute my emergency
there is something to be said for a broad undergraduate education and i feel stronly that the best doc are those who have a broad and extensive med school experience
medicine is an art not the efficient application of facts
7years college, 4 years med school 6 years residency BEFORE 80 hour work week

Skeptical Scalpel said...

The rush is on for a few reasons. College plus med school = massive debt for many. Most people agree that it takes too long. Other countries, which the US healthcare system is always compared to in a negative way, seem to do OK with shorter paths to completion of training. Many feel that a 4-year college degree adds little or nothing to a doctor's eventual skill set.

Anonymous said...

Med school should be five years. The first two are basic science, the third is clerkship, and the final two are a Canadian-style family med residency. Every graduating physician would be able to practice generally, and every MD would be able to apply for specialization at any point in their career rather than only during medical school as it is now.

Let's be honest: medical school, as it stands, is largely a ritual. The curriculum is outdated, and the whole farce exists solely as a fairly inflexible residency selection process, the same way undergrad existed as a medical school selection process.

Skeptical Scalpel said...

Anon, your plan would certainly be an effective way to decrease the number of applicants to medical school. Forcing everyone to do two years of family medicine would be cruel and unusual punishment for many, including patients.

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