Synopsis: In an age of increasing medical complexity, some leading thinkers in medical education are proposing that the time spent on medical education be cut by nearly one third. The key, these advocates say, is ridding curricula of requirements that most doctors never use. Experts discuss both sides of the issue.
Host: Reed Pence. Guests: Dr. Ezekiel Emanuel, Vice Provost for Global Initiatives and Chair, Department of Biomedical Ethics and Health Policy, University of Pennsylvania; Dr. Victor Fuchs, Henry J. Kaiser Professor Emeritus of Economics and Health Policy, Stanford University and Senior Fellow, Stanford Institute for Economic Policy Research; Dr. Gail Morrison, Senior Vice Dean for Education and Director of Academic Programs, University of Pennsylvania Pereleman School of Medicine.
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14-18 CUTTING MEDICAL TRAINING
Reed Pence: Becoming a doctor is hard work. There’s the cutthroat competition to get into medical school in the first place, the grind of four years of medical school, residency, with its three years of legendary backbreaking hours. And finally, a fellowship, where many specialists actually learn their craft. It adds up.
Dr. Ezekiel Emanuel: The minimum is 11 years in the sense that it’s four years of college, four years of medical school, and three years of internship and residency, but if you want to become a specialist, you’re going to have to add four years to that if you want to become a certain kind of surgeon. Yeah, so you’re certainly north of 11 years, let’s put it that way.
Pence: That’s Dr. Ezekiel Emanuel, Vice Provost for Global Initiatives and Chair of the Department of Biomedical Ethics and Health Policy at the University of Pennsylvania. He’s also author of the new book, Reinventing American Health Care, and co-author of a proposal that may strike you as strange. In an age when medicine is getting more and more complex, he’s calling for doctors to get less training, cutting its length by about 30 percent and reorganizing its content.
Emanuel: One of the problems that I certainly point out is we have basically had the same structure of the system for the last 100 years, despite tremendous change in medical practice and different needs. And yet we’re still doing a lot of the same things and, you know, there’s no doubt that we could shorten it and we could change it.
Dr. Victor Fuchs: If you force the people in medical education to think seriously about what they’re doing and what they’re trying to accomplish, that in itself will be a major step forward.
Pence: That’s Emanuel’s co-author of the time-shortening proposal, Dr. Victor Fuchs, Henry J. Kaiser Professor Emeritus of Economics and Health Policy at Stanford University and a senior fellow at the Stanford Institute for Economic Policy Research
Fuchs: Basically, people have been locked in to the lines that were laid down 100 years ago that you have to study basic sciences for two years, then you do clinical rotations for two years, then you go into residencies and you begin to figure out what you want to specialize in, and then you get further training.
Pence: Emanuel says medicine still trains doctors anticipating careers that are a lot more than an office practice. It’s part of the old romantic idea that good doctors are triple threats–clinicians, yes, but also charismatic teachers and cutting edge researchers.
Emanuel: We train people to that end and I think in this day and age, that’s a ridiculous way to train people. First of all, most doctors are going to go into clinical practice. They’re not going to do research and they’re not really going to do a whole lot of teaching, so there’s no reason to add those elements to their training, it’s just a very bad waste of time. And second of all, I think there are lots of things related to the clinical practice that we don’t do well today. So for example, most of the training in the medical school, the two years of clinical training are done in a hospital. Most of the training of a resident and an intern, here I mean most as in 90%, is also done in a hospital, yet most doctors are going to practice in an office, not in a hospital. That seems like a mismatch, a very bad mismatch.
Pence: Emanuel and Fuchs advocate reorganizing medical school as well as shortening it. Today, its four years are typically divided into two years of studying basic science like biochemistry and anatomy and then two more years of clinical training.
Emanuel: The two preclinical years I think are widely recognized not to require two years of training. So, for example, leading medical institutions in this country, Duke and Yale, are down to one year. My own University of Pennsylvania is at a year and a half. You certainly can lop out a year if you don’t want to be so extreme, you could lop out half a year of that training with no damage done. And if you think people then need two years of clinical work, you know, you’re down to three years of medical school training, that’s a 25% time cut and you haven’t lost anything.
Pence: However, a lot of experts in medical education disagree. To many of them, shortening med school might be the last thing we should be considering.
Dr. Gail Morrison: Medical schools are changing how they pace and train students. The question is can you do it in three years for everybody? Three years is not a very long time, given a couple of other things. One, a third of students that come into medical school are non-science majors.
Pence: That’s Dr. Gail Morrison, Senior Vice Dean for Education and Director of Academic Programs at the University of Pennsylvania’s Pereleman School of Medicine.
Morrison: We know there’s been some articles published from program directors that have questioned even four year programs in saying they’re not convinced that 100% of all students that come out of medical schools are prepared to start their GME training. Medicines become very complicated, in that the fields are much more specific. The patients in hospitals are much sicker than they used to be 30 or 40 years ago and preparing them to therefore leave medical school and go out into what we call their graduate medical education training, where they’re going to now specialize in an area. Residency program directors and directors of these programs are saying we have to make sure these kids are ready when they leave medical school to really work more independently in a hospital setting.
Pence: Medicine has tried to speed up the med school experience before. Back in the 1970’s, a number of schools combined bachelor’s degree and medical school into a six or seven year program, cutting a year or two from the schedule.
Morrison: Those schools lasted for about four years, from 1971 to ’75 and then all of them disappeared. The students didn’t like it, faculty didn’t like it; too intensive, no time to explore anything else they wanted to go into.
Pence: To many medical educators like Morrison, that last point is very important. The system today is set up to allow up and coming doctors the time to figure out what kind of doctor they want to be.
Morrison: Most students that enter medical school do not know what they want to go into in the medical world, what kind of medical field they want to go into. And if they have an idea, literature tends to tell us 80% might change what they go into based on who they meet in medical school and who they work with in medical school. It isn’t like you start something, you don’t like it in college, a major, you can’t do that in the GME world. You have to have funding that flows to you from the hospital in order to pay for you in order to be in a credited program in order to get your GME training. So very, very difficult to switch once you get into a GME program, graduate medical education program, very, very difficult to switch. You certainly want to pick what you want to go into with a fairly high degree of believing you’re picking the right field for yourself.
Pence: However, to Fuchs and Emanuel, that seems like foot-dragging.
Fuchs: Everybody is afraid to make a commitment to a particular field of specialization. They say, “Well, how will I know? You know, I’ve only been in college for four years and I’ve only been to medical school for four years and I’ve had a couple of years of residency, how do I know if I want to be a pediatrician or an obstetrician or surgeon or internal medicine or something like that?” So they often try to delay that final commitment to a specialty as long as possible.
Ezekiel: It’s a very expensive decision-making process. That’s essentially another $90,000 for that decision.
Pence: Fuchs proposes that medical school be reorganized to provide real world experience sooner. He advocates that about a third of the first two years of med school be spent in clinical rotations with patients.
Fuchs: At the end of those two years, I’m suggesting that those medical schools develop tracks. Now, a track would be a half-way house between a specialty and just general medicine. It wouldn’t be a full-scale commitment. For example, you could have a track for people who know they want to do some kind of surgery but they don’t know whether it’s heart surgery or stomach surgery or brain surgery. So for those two years, they would get more intensive preparation for a life as a surgeon, but they wouldn’t be getting all the things that have to do with the other types of medicine. It would be somewhat specialized but not completely specialized.
Pence: Then after another two years, new doctors could move into further specialization in residency. Medical education is moving in that direction, not in quite the way Fuchs proposes, but toward tracks in a way that Morrison says makes sense.
Morrison: Once you’ve decided what you want to be, putting that individual into the right track for where they think they want their career to be following their specialty training is probably the place to shorten medical training. Now there are five-year programs where you enter directly from medical school into thoracic surgery programs, shortening by three years your residency and fellowship training programs.
Pence: Emanuel admits to treading gingerly with residencies. He doesn’t think they should be cut very much, but subspecialty training later on in fellowships is another story.
Emanuel: In what’s called the fellowship or the sub-specialty training to become a cardiologist or an oncologist, which is what I do, when I was training to be an oncologist which is true today, you had one clinical year and then you had two years of research. Well why are you getting two years of research if most people who are going to be trained as oncologists are going to be clinical practitioners and they’re not going to be designing and running clinical trails or even lab research. That doesn’t make sense. That is a waste of two years for most people.
Pence: The real question is whether the time spent in medical training is used wisely. Does spending a couple of years in research mean that your doctor will give you a more thorough physical, or come to a more well considered diagnosis? Are doctors trained to be triple threats better doctors than those trained to be merely clinicians?
Emanuel: There’s no good evidence, and there may be actually good evidence, especially in the procedure-dependent fields where they’re actually not better. You know, one of the thing we know about procedures like surgery is that the more you do them, you tend to become better at them and decrease errors and things like that. And, you know, if you stop your practice and you’re mainly doing research, it’s pretty unlikely you’re going to get a large volume, it’s pretty likely you’re going to be forgetting some of the things you used to do and have to re-learn it and that’s not an ideal way, operating one day a week, for example is not optimal.
Pence: Medicine does seem to realize that a system devised 90 years ago could be ripe for change, especially in an age when there’s a shortage of doctors in primary care. New doctors need to be produced sooner rather than later. Fuchs says he’s been surprised at how little opposition there’s been to their plan to cut medical training. But Emanuel admits, it’ll take time.
Emanuel: By the end of the decade, I think we’re going to be down to three-year medical schools and we’re going to change the substance of what we teach because I think we’re not training doctors now who are appropriate to the evolving medical healthcare system so I think that’s going to have to change. First of all, I recognize that when I make predictions I could be wrong and I do recognize that medical schools are probably the slowest-evolving institution structures there is.
Pence: You can find out more about all of our guests and their publications through links on our website, RadioHealthJournal.net
I’m Reed Pence.