Reform medical education to ease doctor shortage
Ihad just finished an eye examination for one of my patients and swiveled around to the computer. It was clear that he needed cataract surgery; he was nearly blind despite his Coke-bottle glasses. But even before I logged into the scheduling system, I knew what I was going to find: He wouldn’t be able to get an appointment with an ophthalmologist for more than three months. Everyone’s schedule was full.
Moments like these are far too common in medicine. An aging population with numerous health needs and a declining physician workforce have combined to create a physician shortage — the Association of American Medical Colleges projects a shortfall of up to 100,000 doctors by 2030.
Policymakers have proposed many solutions, from telemedicine to increasing the scope of nurse practitioners. But I can think of another: Let students complete school and see patients earlier.
U.S. physicians average 14 years of higher education (four years of college, four years of medical school and three to eight years to specialize in a residency or fellowship). That’s much longer than in other developed countries, where students typically study for 10 years. It also translates to millions of dollars and hours spent by U.S. medical students listening to lectures on topics they already know, doing clinical electives in fields they will not pursue and publishing papers no one will read.
Decreasing the length of training would immediately add thousands of physicians to the workforce. At the same time, it would save money that could be reinvested in creating more positions in medical schools and residencies. It would also allow more students to go into lower-paying fields such as primary care, where the need is greatest.
These changes wouldn’t decrease the quality of our education. Medical education has many inefficiencies, but two opportunities for reform stand out. First, we should consolidate medical school curriculums. The traditional model consists of two years of classroom-based learning on the science of medicine (the preclinical years), followed by two years of clinical rotations, during which we work in hospitals.
Both phases could be shortened. In my experience, close to half of preclinical content was redundant. Between college and medical school, I learned the Krebs cycle (a process that cells use to generate energy) six times. Making college premedical courses more relevant to medicine could condense training considerably.
Meanwhile, the second clinical year is primarily electives and free time. I recently spoke with a friend going into radiology who did a dermatology elective. While he enjoyed learning about rashes, we concluded it did little for his education.
In the past decade, several schools have shown the fouryear model can be cut to three. For instance, New York University offers an accelerated medical degree with early, conditional admission into its residency programs. The model remains controversial. Critics contend that three years is not enough time to learn medicine. Yet a review of eight medical schools with three-year programs suggests graduates have similar test scores and clinical performance to those who take more time.
Finally, we can reform required research projects. Research has long been intertwined with medical training. Nearly every medical school offers student projects, and more than one-third require them. Many residencies do as well. Students have responded: The number pursuing nondegree research years doubled between 2000 and 2014, and four-year graduation rates reached a record low. Rather than shortening training, U.S. medical education is becoming longer. The additional years aren’t even spent on patient care.
Done right, this could still be a valuable investment. Intellectual curiosity and inquiry drive scientific progress. But that’s not why most students take research years. I conducted a study showing that less than a quarter do so because of an interest in the subject matter. The most common reason was instead to increase their competitiveness for residency applications.
And because having more research published represents greater achievement in academic medicine, students are presented with a bad incentive to publish a large amount of low-quality research. Many of my peers have recognized this, producing more papers than many faculty members. It’s no surprise that there has been an exponential increase in student publications in the past few decades, even though a majority are never cited.
Medical schools need to realign incentives. This starts with the recognition that students can do valuable work even if it doesn’t end up in a journal. It’s time we get them out of school and in front of patients.
Akhilesh Pathipati is an ophthalmology resident at Harvard University’s Massachusetts Eye and Ear Infirmary.