Sunday, May 24, 2009

Three Year Medical School - An Idea Whose Time Has Finally Come?

“Decreasing the duration of medical education offers the greatest potential for reducing the financial burden of medical education.”

Oddly enough, the current push at the University of Minnesota Medical School seems to be to lengthen the amount of time that elapses in obtaining a medical education - in which the administration seems to take pride - see the late MED2010 initiative.

But what really ought to be happening is a re-tooling of undergraduate and graduate medical education to reduce the time, and especially expense, of medical education. The tools to do this have been around for a long time. One example is the six year combined MD-undergrad program at Northwestern. Another worthwhile shortening is the suggestion that one term of organic chemistry would suffice in the education of many physicians. Whether they need to know about nucleophilic aromatic substitution is dubious.

Another possibility is shortening the medical curriculum so that it is completed in three, rather than four years. This seems eminently doable. Unfortunately the attempt to totally mash up the academic side of programs makes it difficult for a med student to skip say, biochemistry, if she has had an excellent undergrad course and paid attention.

From Web Weekly, News From the Harvard Medical Community

To Cut the Costs of Medical Education, Trim Training

It is no secret that medical training is long. Whether at cocktail parties or family reunions, the student doctor stays on alert for the well-meaning if often-repeated question: “How much longer do you have left?”

Opportunity knocks for the first entrepreneur since the 1970s who can establish a three-year American medical school pathway.

At the college level, premed requirements of the Association of American Medical Colleges (AAMC) take about one and a half years. The expectation is that this period allows adequate preparation and that all medical school applicants take the standardized MCAT. But concern remains among medical educators that science education is not equal across campuses, so much time is lost during the first year of medical school getting everyone up to speed.

Potential solutions include:

• Formalizing curriculum accountability between medical and undergraduate faculties at institutions that have both schools;

• Accrediting premedical programs;

• Improving MCAT psychometrics.

Making the Cut

During the early 1970s nearly one quarter of American medical schools established flexible three-year programs, but these fell quickly out of favor by the end of the decade. Yet in 1988, Robert Ebert, who was the HMS dean from 1965 to 1977, and Eli Ginzberg, Columbia economist and presidential adviser, raised a similar call to action in a Health Affairs article. Though AAMC reports in the early 1990s acknowledged the cogency of their argument for increasing flexibility in medical education, the four-year pedagogy grew more ingrained, particularly in the context of flourishing basic science departments.

Today, medical debt headlines as a priority for the AAMC, American Medical Association, and nearly every student group who can post a blog, but the hand-wringing tends to push aside solutions from other sectors: cutting costs (i.e., reducing training length) and growing top-line revenue (i.e., increasing housestaff salaries).

Enter E. Ray Dorsey et al.’s 2006 Academic Medicine study, once again providing a compelling economic perspective: “Decreasing the duration of medical education offers the greatest potential for reducing the financial burden of medical education.”

The findings include:

• One year less of medical school yielded a net present value (NPV) benefit ranging from $160,000 to $230,000 (using a 6 percent discount rate in the calculation);

• Increasing residency compensation to that of a first-year physician assistant yielded an NPV benefit ranging from $60,000 to $100,000;

• Reducing medical school tuition by 25 percent had the smallest financial impact—$30,000.

Paradigm Shift

Economics is important, but would a three-year MD play in Peoria?

To allay concerns about shaking up the four-year precedent, I would cite the 34 BS/MD programs that typically last six years, as well as the shorter total duration of most foreign medical schools (usually entered as an undergraduate).

As for logistics, the standard four-year track could take a haircut either at the front or the back. Time and energy invested in premedical courses (from general chemistry to molecular biology to statistics) should tee up matriculants to tackle the exciting science of clinical medicine. Even allowing room for a short refresher course, this classroom-based work could be completed in one year, enabling future physicians to start laying hands on patients—the soul of a healer’s training—in their second year. And on the back end, the predominance of electives in the fourth year could be combined rather easily with internship to recreate a more transitional year.

Change is unlikely under the auspices of committees and task forces. The ideas are before us, and as in so many areas of clinical services, we need leaders who will start pilot programs. For a profession grounded in the scientific method, it is surprising that providers are so reluctant to experiment with entirely different training methods.

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