Tuesday, October 29, 2013

Three Years of Medical School?

I read an interesting article in the New York Times the other day.  Called, "Should Medical School Last Just Three Years?" it outlines a movement by some medical schools to compress the current four year schedule into three years.

To give some background for this, let me outline the typical current medical school curriculum.  The first two years are the "basic science" years.  The first year (at least when I went to school)  typically covers anatomy (including cadaver dissection), physiology, microbiology, biochemistry, histology, and statistics. The second year covers pharmacology, pathophysiology, neurobiology, and epidemiology.  Years 3 and 4 are the "clinical years."  Third year students spend their time on six-week rotating clerkships through the core areas of medicine- internal medicine (this one was 12 weeks), pediatrics, OB/GYN, surgery, psychiatry, and family medicine.  Fourth year is an elective year, used to explore subspecialty areas such as dermatology, plastic surgery, and ophthalmology.  It also has the all-important "sub-internship."  This is an opportunity for the fourth year student to take on the role of an intern on a team, usually in whatever specialty they plan to go into.  I obviously did my "sub-I" in internal medicine.  It was incredibly valuable- more on this later.  The fourth year also has a decent amount of time dedicated to applying to and interviewing at residency programs (time-consuming and expensive) and studying for the second step of the licensing boards.

Proponents of compressing medical school seem to have three main motivations.  Here are each of them, with my response.

1.  There is a projected physician shortage.  Compressing medical school will produce more physicians.

Shortening medical school will produce more physicians for exactly one year- the initial year of implementation.  As long as class size remains the same, after that first year the same number will graduate every year.  In addition, there are a set number of residency spots in the USA.  The number of spots is tightly controlled by Medicare, which funds the graduate medical education program.  Without more funding for residency programs, there is NO WAY to increase the amount of doctors.  There will just be more MDs without residency training who therefore can not be licensed.

As if this wasn't enough- we need to train the right kind of physicians.  We need more primary care docs, not more specialists.  Very few would disagree with this.  Producing more doctors is worthless unless they are more primary care docs.

2.  Medical school is expensive.  Most students graduate more than $150,000 in debt.

So, something is too expensive, and the solution is to get rid of it?  How about...revising the cost of medical school?  Creating better loan programs?  Creating loan repayment incentives?  I can think of plenty of ways to reduce cost, short of discarding a year.  That's throwing the baby out with the bathwater.

3.  The fourth year is useless, filled with low-key relaxing electives.  The lead author of the proposal even says:
“We can’t dissociate medical education from societal and student needs,” said Dr. Steven B. Abramson, lead author of the perspective piece in favor of three-year programs and vice dean for medical education, faculty and academic affairs at N.Y.U. “We can’t just sit back in an ivory tower and support a mandatory year of prolonged adolescence and finding oneself, when society needs doctors to get out into the community sooner.”

This line of reasoning annoys me even more than the others.  For me, the fourth year was incredibly valuable.  My medicine sub-I was amazing.  My team, the patients and the nurses treated me like a physician.  It was my first opportunity to truly take responsibility of my patients and my actions, but yet still have someone looking over my shoulder.  "Prolonged adolescence?"  I think not.  After my sub-I, I did rotations in ophthalmology, dermatology, urology, reproductive medicine, and physical medicine and rehabilitation.  All of those taught me things that I use to this day.  I did a study abroad rotation in Edinburgh.  It was great to experience health care in another country.  I honestly think I would have missed out on a lot had I not had a fourth year.

Let's also not discount what life experience and age add to creating a physician.  When I did my rotation in Scotland, I worked with medical students there.  In Scotland, students do a six year undergrad/medical program rather than the 8 years that we do here.  On the whole, I noticed a difference in the maturity level between the med students there and the ones in my class back in Rochester.

Compressed programs have been tried in the past- six and seven year combined BS/MD programs and 3 year MD programs. Pretty much all have failed after a few years.  Students we exhausted by the pace.

Are we trying to produce robots or physicians that are also people?

Medical school should not be compressed.  At the rate that medical science is advancing, I think a more cogent argument could even be made for lengthening it.

It's not the medical education system that needs fixing.

What needs fixing is the entire US healthcare system.


  1. Couldn't agree more! Curriculums have changed quite a bit. At Penn the students start clerkships after just 1.5 years. But many students do extracurricular and unique things such global health, masters in epi/public health etc.. I predict this will just lead to extended residency training. We have already seen this in pathology. I had to do five years and then it got shortened to 4. Now almost every resident goes on to fellowship and many do multiple fellowships. Hope your back pain is lessening!

  2. Send Dr. Steven Abramson and the NY Times Editorial a copy of this blog in response to his adolescent proposal. Who would suffer? THE PATIENT!!!

  3. Medicine is an art learnt and practiced with rigourousness of time. No shortcuts. Primary care is the strength of a health system. This is what this country needs. Not subspecialists. To create more doctors I feel the education should change to medical school systems in developing countries. U do ur med school yr and do a 1 yr mandatory internship. During the internship u rotate through med surg and obgyn and aquire skill set to provide care as a family practitioner. Thus u will have doctors for providing pt care on a primary care level. In many developing countries because of the paucity of doctor after med school and internship they do a mandatory service in areas with physician shortages. Incorporating such changes here is difficult but this health system can only be saved by strengthing its primary care facilities