Shortening Medical Training by 30%

[235009]

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http://jama.jamanetwork.com/article.aspx?articleid=1105095

interesting read. personally i think the easiest places to cut would be on the far ends of medical education - namely premed and preclinical years as well as fellowship training. I hear that in peds there's already a push to shorten fellowships.

thoughts?

(i'm only posting this in pre-allo because this forum gets the most traffic. this article is applicable to those at every level of training)

 

[circulus vitios]

Aren't 3 year medical school programs just as expensive as 4 year programs? They will get their pound of flesh one way or another.

 

[Hernandez]

30% less med school but now with 100% residency and 200% more debt!

Sorry kids, but unless there are some deregulation or serious changes to the post-grad training, residency ain't going to get shorter. It WILL need to be extended. And in adult medicine fellowship, the trend is to get longer, generally by way of additional sub-sub specialties (think sleep, or heart failure, or echo, etc)

 

[oldbearprofessor]

http://jama.jamanetwork.com/article.aspx?articleid=1105095

I hear that in peds there's already a push to shorten fellowships.

In peds some are talking about extending residency to 4 yrs. Some are talking about expanding the possibility of moving more quickly from residency into fellowship. Some want to create a shortened clinical fellowship.

Reality? Very unlikely to see any real changes in the next few years. Even more unlikely to see the current 6 post-graduate years from starting residency to finishing fellowship shortened at all.

Sorry. I don't see it happening.

BTW - in some fields, including pedi cards, there is definitely a trend towards sub-fellowships of an extra year. Not so much in most areas though.

 

[calvnandhobbs68]

I actually do think you could cut out a year or two of college without any problems but people always get super pissed about that. It's been going on with BS/MD programs for a while now.

Residency isn't gonna be shorter because the parts he suggests cutting out (the final years) are the years when hospitals start making the most money off their residents. Don't think they'll be too keen on cutting that short.

I think the author affiliations are interesting...the one is at UPenn (basically saying look how awesome our school is everyone should do it this way) and the other is an economist at Stanford. I mean he's a health economist but still not exactly an expert on clinical training.

 

[whatbout2morrow]

Aren't 3 year medical school programs just as expensive as 4 year programs? They will get their pound of flesh one way or another.

Yeah, but that's one added year of attending physician earning potential and one year less of interest on loans.

 

[alpinism]

In reality schools could easily cut half of M4 and shorten M1 to half. Alot of M1 is just a review of undergrad biochem, genetics, cell bio, etc...anyway. Then just make it a 3yr degree like duke does already but w/o the research year. But then they wouldn't get their extra yr of tuition...

 

[235009]

Residency isn't gonna be shorter because the parts he suggests cutting out (the final years) are the years when hospitals start making the most money off their residents. Don't think they'll be too keen on cutting that short.

it obviously wouldn't be the hospitals making this decision. as the article points out it would be the government deciding to cut back on funding for residency training that would have to force such a change.

 

[sibitrum]

It's interesting how the US' medical education system mimics its K-12 system. Both are afraid of students specializing too soon or "closing too many doors". And both end up being significantly less efficient for it.

 

[SoulinNeed]

Why not just do what the rest of the world does and make a medical school education six years after HS? Instead of 4 years of undergrad+ 4 years of medical school, just have 2 years of the current pre-med prerequisites, then the typical four years of med school?

 

[Slack3r]

30% less med school but now with 100% residency and 200% more debt!

Sorry kids, but unless there are some deregulation or serious changes to the post-grad training, residency ain't going to get shorter. It WILL need to be extended. And in adult medicine fellowship, the trend is to get longer, generally by way of additional sub-sub specialties (think sleep, or heart failure, or echo, etc)

Yup, while we keep advocating for more training, midlevels are legislating their way into the same practice rights in a fraction of the time.

I find it amusing that while NP's are pushing for (and being granted) independent practice rights in specialties like FM, gaining equal reimbursement for pain procedures, ODs receiving surgical privileges, and CRNAs pushing to practice outside the ACT model, it's still anathema that medical training be altered or shortened in any way. Something is going to have to give somewhere.

 

[mimelim]

You can cut out all pre-med and M1. They are completely irrelevant to being a physician. The biggest problem with doing this is that you end up with less mature people entering clinical training. Less independence, less ability to think through things on their own etc. That is an issue, but the raw content of everything prior to M2 is just plain useless.

About shortening residency. I am in a 7 year surgical program. I feel it is too short. I would have liked to start it earlier in my life, I am starting at 26, just about the earliest you could. But, I would prefer to have another clinical year in my residency, just to increase my case volume.

 

[angldrps]

You can cut out all pre-med and M1. They are completely irrelevant to being a physician. The biggest problem with doing this is that you end up with less mature people entering clinical training. Less independence, less ability to think through things on their own etc. That is an issue, but the raw content of everything prior to M2 is just plain useless.

About shortening residency. I am in a 7 year surgical program. I feel it is too short. I would have liked to start it earlier in my life, I am starting at 26, just about the earliest you could. But, I would prefer to have another clinical year in my residency, just to increase my case volume.

this is definitely new info for me. I knew premed is useless but didn't think M1 is considered irrelevant too.

 

[syoung]

this is definitely new info for me. I knew premed is useless but didn't think M1 is considered irrelevant too.

What exactly is the point of M1 then... if it's irrelevant or a repeat of ugrad bio/chem/phys/anat/mol/imm/etc etc etc?

 

[angldrps]

What exactly is the point of M1 then... if it's irrelevant or a repeat of ugrad bio/chem/phys/anat/mol/imm/etc etc etc?

yes i would like to know this too. is it just info to pass step 1?

 

[MT Headed]

In reality schools could easily cut half of M4 and shorten M1 to half. Alot of M1 is just a review of undergrad biochem, genetics, cell bio, etc...anyway. Then just make it a 3yr degree like duke does already but w/o the research year. But then they wouldn't get their extra yr of tuition...

What exactly is the point of M1 then... if it's irrelevant or a repeat of ugrad bio/chem/phys/anat/mol/imm/etc etc etc?

These classes are not pre-reqs. If you forced students to study these in undergrad then some schools (like mine) would be incapable of training pre-meds, and for those of us that aren't biology majors you'd probably just extend the undergrad experience by one year while lopping it off of medical school.

With that kind of logic, why not make path, histo, pharm, etc. pre-reqs and then you could shorten medical school by two years?

 

[oGatsby]

.

Why not just do what the rest of the world does and make a medical school education six years after HS? Instead of 4 years of undergrad+ 4 years of medical school, just have 2 years of the current pre-med prerequisites, then the typical four years of med school?

Here's my bit on college:

I don't expect anyone in America to know what they want to do or whether or not to become doctors before they're 18 even though I've made my choice. I don't expect them to know what they want to do at all.

Furthermore, and what I think is more important than that point, is that I don't expect someone who is fourteen to think that far ahead, to grow up so early, and get the grades that will determine the rest of their lives. It is much better, then, to give students the chance to grow up, the chance to screw up, in the hopes that they will turn it around in college and get the grades for the profession they want.

In this way, the American school system is actually one of the most forgiving systems on the planet. We let you **** up as much as you want, we drag you kicking and screaming to graduation, and then when you're accepted to college, we go "Good luck kid. Nobody cares if you fail anymore. Make the best of it; you have the freshest start you're going to get. You are free."

That's monumental. If all you looked at was me in high school, I couldn't be a doctor, but this past summer, I have manned up, worked harder, prestudied, and become the person I wanted to be, who I need to be, to get where I want to go.

Everyone deserves a second chance. That's what college is for.

I do not support the shortening of medical education, and I do not support the straight out of high school fast track. There are plenty of places for people who do to go, both at home and abroad.

Putting in a six-year, European style system would call for European style admissions: Heavy emphasis on standardized tests, like A-levels, less emphasis on extra-curriculars (which are bull**** anyway), and classroom grades (doublebull****). While that is a system I support, I don't see the point being made, that we would have to convert, in this thread. .

 

[tn4596]

with the availability of AP courses and summer schools, you can graduate high school and college in 6 years with ease, which mean you still be 20 when you graduated from college. If you work hard at all in middle school, you can also test out of classes and move up a grade. It is also common to see 16 year old high school graduates. I am 20 and graduated. I never took summer courses in college or high school; so you can graduated from college even quicker than I did. all you need to do is to plan all your courses well ahead, make sure all your course meet the degree requirement and dont take any unnecessary courseworks. you dont need to take AP credits fo any prereq courses either, all my AP credits is for government, economic, theater art, history... (30 credit which is about 2 semesters of college courseworks). The disadvantaged is that you will always be the young one compared to your peers. It also sucks when all your friends are 21, and some bars/clubs only allow 21 or older to enter.

 

[Law2Doc]

What exactly is the point of M1 then... if it's irrelevant or a repeat of ugrad bio/chem/phys/anat/mol/imm/etc etc etc?

It's not. The first 10-15% of each block might be review if you've had a lot if science courses in undergrad, but after that there's a ton you will not have seen at the undergrad level. Also frequently med school profs need this "review" to undo all the black pearls and inaccuracies folks pick up in many college courses, which often oversimplify certain things in ways that are msleading and counterproductive. Interestingly, a lot of folks for whom this is supposedly "review" struggle on the med school exams each year - you'll see a good mix of science and non-science majors at both ends of the class rank. College is like drinking out of a water fountain, med school is like drinking out of a fire hose. You need first year to ramp up because second year comes at you even faster.

As for shortening residency/fellowship, I think that notion represents a frame of reference of someone not actually that far into training. Residency already represents a compromise between how much info there is to learn and actually getting out into practice in a timely fashion. You need a LOT of training in most fields, but can't be a trainee forever. Those of us further along can tell you that residency barely scratches the surface of what you need to competently practice in many fields, and in some fields is probably a bit short as is, and that as you get further along you are working harder and harder to milk as much value a possible out of each day because in an extremely short time you will be working without a net. I think more credible arguments could be made that some fields should be extending residency as duty hour cuts are made, rather than suggest paring things down.

The one area I might agree is 4th year of med school after the match. You probably get more value just ending med school the day after the match, give folks a month off to relocate, and have folks start residency in early May instead of the end of June. Those two extra months of residency would be of more educational value than taking a few months of joke electives, and at least you'd get two extra months of residency salary. But I don't think shortening the time from undergrad to attending is useful.

There used to be a few 2 year med schools for certain PhDs in life science fields, where they cut out all of the holidays and redundancy, and got these folks to residency much faster. The LCME ultimately decided this was a bad idea and closed them all in the 80s. I don't think things have changed -- if anything there is even more to know in the last 30 years.

Bear in mind that JAMA in particular loves to publish the more controversial topics, and generally these articles get trashed in journal clubs in hospitals throughout the nation. As OBP suggests above, this one runs against the grain and in many key respects doesn't reflect the beliefs of academic physicians across the nation. Wouldn't bet on a change.

 

[Alejandro]

Personally, I'd like to see more work experience become a standard requisite for premeds, simply because it seems that most people haven't had a real job in their lives upon entering medical school. Being a doctor is still a job, just like being a janitor or an executive-you still have responsibilities to do your job well, show up on time, and be accountable. I think having some real-life experience could offset the "lack of maturity" issues for a truncated medical program.

But how would one quantify which work experience as adequate? That's where I feel that this would get stuck. For example, McDonald's vs an ER tech....?

 

[Long Way to Go]

It is also possible to reduce residency training by 1 year. For internal medicine, pediatrics, and similar 3-year residencies, the third year is not essential to ensure competent physicians. This residency year is mainly engaged in supervising and teaching interns, in taking electives, or in some cases conducting research. While valuable, these activities are hardly essential to becoming a knowledgeable practitioner. Indeed, many trainees are permitted to short track into subspecialty fellowships, reducing their residency from 3 to 2 years. Shortening training in an era of work-week limits will force hospitals to reengineer programs to ensure residents' clinical competence—a worthwhile exercise.

A lot of the rest of the article makes sense even if you don't agree with it. I don't really understand this part though. Is two years really enough time for someone just out of (a shortened, if these guys had their way) medical school to become a fully board eligible hospitalist?

 

[Hernandez]

A lot of the rest of the article makes sense even if you don't agree with it. I don't really understand this part though. Is two years really enough time for someone just out of (a shortened, if these guys had their way) medical school to become a fully board eligible hospitalist?

Absolutely not, unless you do away with the work hour restrictions, as it stands now I'm not really sure many of these kids coming out of many medicine residencies are competent at 3 years, and IMHO; with the new work hour rules, many medicine residencies should be 4 years.

Now if we wanted to have people test out of the 3rd-4th year with an in depth oral boards, that would be acceptable to me.

 

[alpinism]

These classes are not pre-reqs. If you forced students to study these in undergrad then some schools (like mine) would be incapable of training pre-meds, and for those of us that aren't biology majors you'd probably just extend the undergrad experience by one year while lopping it off of medical school.

With that kind of logic, why not make path, histo, pharm, etc. pre-reqs and then you could shorten medical school by two years?

eh I was more referring to condensing the M1 classes rather than removing any.

M1 classes are definitely more in depth and have a much greater volume of material than UG. However, as others have said, IMHO much of it is irrelevant to being a physician. You end up memorizing thousands of pages of minutiae of which >50% you'll never use again (except when re-learning it for step 1).

Basically there is a ton of fluff and many of the courses could be trimmed and streamlined, leaving the high-yield material intact. Either way it shouldn't affect non-bio majors in UG.

In this case you would end up w/ a curriculum like UPenn (start clerkships Jan M2, end Jan M3) but then just cut half M4 making it 3yrs total.

 

[JustDOG]

Just a little FYI. The 2 medical schools in Canada which are mentioned in the article do run three year programs, however all that happens is that there are no summer breaks. All four years are condensed into three. I know some students from one of the programs. They like it, it is tiring, and because of the time frame of applying for residency, they don't always feel like they have had the exposure necessary to be deciding quite yet the specialty they wish to pursue. Cost wise it is more per year, but overall they pay one less year so it is on par. My feeling is that by the time we get to med school we are in a professional program, so let's go ahead and condense it, but the school would really need to watch for burnout etc more closely.

 

[ceasefire]

this is definitely new info for me. I knew premed is useless but didn't think M1 is considered irrelevant too.

Personally, I think M! can be condensed to avoid redundancies (like RAAS). M1 +M2 could be condensed into either 1 or 1.5 years.

I live with two residents (one EM, the other IM) and they said that the first year was full of useless information that they don't need to know. In the second year, they had a brief reminder of normal physiology before they delve into pathophysiology, and they said this would have been sufficient.

Nobody apparently cares that you can draw out the Krebs Cycle or calculate the Nernst in your head.

 

[neoevolution]

Reducing undergrad to 3 years would work. Plenty of BS/MD programs operate with 2 or 3 years of undergraduate study, why not allow medical school admission without a bachelors as long as the person has the necessary prereqs? I understand the maturity debate, but other countries have a combined college and medical school system, and the medical programs in the US already operate this way.

 

[Law2Doc]

...I understand the maturity debate, but other countries have a combined college and medical school system, and the medical programs in the US already operate this way.

Nah -- The combined programs have fallen out of favor, and there are fewer of them every year, so pointing to them as a solution is basically like trying to get water to flow upstream against a waterfall. The (right) decision has already been made regarding shortening undergrad -- that idea has more or less been rejected. It's never useful to point to other countries because the demands of US physicians and patient expectations are quite different than in foreign countries. You will see plenty of foreign trained doctors struggle with many of the non knowledge based aspects of US practice, some of which are the core of what medicine is here.

 

[Parklife]

I think everyone is seriously underestimating the importance of time. Experience is the best teacher. I haven't gone to any sort of grad school yet, but this is my bit. Right now I'm about a year and a half ahead. However, instead of applying early, I'm going to double major. Why? Because I'm 19 for God's sake. I understand that being in school for so long, one just wants to live life, but life can be lived just as well(much better actually in undergrad)

I think UG serves as a way for students to mature and grow. Personally, I learn a lot and I enjoy my electives. Little tid bits I pick up from spanish, philosophy, speech, anthropology, nutrition, history, etc. It's important. Maybe not every student is excited for history class, but I think classes like political science and economics should be graduation requirements. Like everyone has pointed out, not everyone is a gunner pre-med from age 16.5. People change and grow in undergrad. I think if we shorten this, then we're going to have even MORE people trying to become doctors without actually knowing what it is to be one.


Maybe shortening med school and extending residency is a good idea, but I don't think we should mess with undergrad. Undergrad serves more of a purpose than spending days studying for o-chem and p-chem. You make life long friends in undergrad, you can go abroad for undergrad, take classes that interest you, you can join organizations that mean something to you, you can make mistakes, you can explore yourself.

That's my .02

 

[sibitrum]

Nah -- The combined programs have fallen out of favor, and there are fewer of them every year, so pointing to them as a solution is basically like trying to get water to flow upstream against a waterfall. The (right) decision has already been made regarding shortening undergrad -- that idea has more or less been rejected. It's never useful to point to other countries because the demands of US physicians and patient expectations are quite different than in foreign countries. You will see plenty of foreign trained doctors struggle with many of the non knowledge based aspects of US practice, some of which are the core of what medicine is here.

What is it that you think makes the US so exceptional that it needs to give its students several extra years of education? Don't forget; there is a large opportunity cost for this extra education.

 

[Law2Doc]

What is it that you think makes the US so exceptional that it needs to give its students several extra years of education? Don't forget; there is a large opportunity cost for this extra education.

No not exceptional, different. Patients have different expectations and rights. They are also quite litigious here. Doctors are expected to conduct themselves in certain ways. In foreign countries doctors make more of the decisions and expectations from healthcare are far lower. So here it's less about just having the medical knowledge and more about having the wherewithal to navigate your way through a legally complex service industry. All this requires more "seasoning", maturity, and a broader knowledge base. So it's pretty pointless to say "hey an 18 year old can do it in Germany" when the truth of the matter is it's really comparing apples and oranges. In both countries they call it medicine but the practice is very different.

The opportunity cost argument is flawed -- all the arguments for shortening the path assume the job can be done with less education and/or training. But most would argue that as duty hours get cropped down the product coming out of residency is barely qualified to do the job as is, and there are many making very credible arguments that certain specialty residencies now ought to be lengthened. You have to be very careful on the preallo board asserting that you know what you are and aren't going to need a decade further out. I'm finding you need most of it -- With probably a whole lot more you wish you could retain to boot. Residency seems painfully short the further you get into it -- you are speeding toward the end of the tunnel and the light you are seeing is a train called liability. Oh how you will wish for more tunnel.

 

[sibitrum]

No not exceptional, different. Patients have different expectations and rights. They are also quite litigious here. Doctors are expected to conduct themselves in certain ways. In foreign countries doctors make more of the decisions and expectations from healthcare are far lower. So here it's less about just having the medical knowledge and more about having the wherewithal to navigate your way through a legally complex service industry. All this requires more "seasoning", maturity, and a broader knowledge base. So it's pretty pointless to say "hey an 18 year old can do it in Germany" when the truth of the matter is it's really comparing apples and oranges. In both countries they call it medicine but the practice is very different.

Fair enough. But what if there was substantial tort reform in the US? Then patients wouldn't have so much power over physicians.

 

[diagonal]

The 3rd and 4th years of med school can be consolidated to 6 months, and that's being generous. The amount of wasted time and bull**** on rotations is utterly disgusting.

 

[Law2Doc]

The 3rd and 4th years of med school can be consolidated to 6 months, and that's being generous. The amount of wasted time and bull**** on rotations is utterly disgusting.

I'd say most rotations are actually very high yield if you are proactive. The folks who get hit with the scut the most tend to be the ones who don't show any interest in doing the cooler stuff, and instill no confidence in the residents that they want to do something more. Also scut is in the eye of the beholder -- 90% of what med students whine is scut usually isn't, it's a lot of the same stuff you are going to be asked to do as a resident, early attending and so on.

 

[diagonal]

I'd say most rotations are actually very high yield if you are proactive. The folks who get hit with the scut the most tend to be the ones who don't show any interest in doing the cooler stuff, and instill no confidence in the residents that they want to do something more. Also scut is in the eye of the beholder -- 90% of what med students whine is scut usually isn't, it's a lot of the same stuff you are going to be asked to do as a resident, early attending and so on.

Where did I mention scut. Doing 2 hours of actual work, yet having to be there for 8 hrs, isn't scut. It's just ****ing stupid. And please don't play the "where did you go to med school, because all my days were filled with rich learning and life-altering exploration" card. I know it's a lie.

And if you are so brainwashed as to think my 6 mo point was wrong, well then how about this: no rotation needs to last longer than 4 weeks. If I'm going to be an IM doc, I'll learn IM in residency, thanks. Same goes for every other ****ing specialty.

 

[Charles_Carmichael]

http://jama.jamanetwork.com/article.aspx?articleid=1105095

interesting read. personally i think the easiest places to cut would be on the far ends of medical education - namely premed and preclinical years as well as fellowship training. I hear that in peds there's already a push to shorten fellowships.

thoughts?

(i'm only posting this in pre-allo because this forum gets the most traffic. this article is applicable to those at every level of training)

Take what I write with a grain of salt since I only finished M1 year.

It's an interesting idea. I can definitely see med school being shortened, at least during the preclinical years, to 1 or 1.5 years if redundancies are removed. I'm pretty sure that'll increase daily workload though. A year of med school was tough enough even with built-in redundancies. I'd probably go crazy if 2 years were condensed into 1. But it can definitely be done.

I disagree with shortening residency training though. I always read and hear about how important residency training is, how it's even more important than med school, how they're thinking of extending residency lengths (unlikely, I know), etc, so I have a hard time agreeing with the idea of shortening post-graduate training.

The easiest place to cut down on unnecessary years is college. Four years of college training isn't necessary to be successful in med school. As others have pointed out, shortened BS/MD programs seem to graduate students just fine. I think something like one-year of prereqs after high school before starting med school could be feasible. Have people apply during high school, so they don't start that year of prereqs not knowing whether they'll be in med school next year or not. That cuts down on 3 years right there. That already is almost the 30% reduction in training time that the authors suggest, but without cutting down on anything med school, residency, or fellowship-related. At the same time, leave the traditional 4-years of college --> med school route open for the people who want the college experience before starting med school.

 

[drizzt3117]

Fair enough. But what if there was substantial tort reform in the US? Then patients wouldn't have so much power over physicians.

It's the culture here, also no one really supports tort reform other than doctors.

 

[plumazul]

It's the culture here, also no one really supports tort reform other than doctors.

It's a bit more than "culture". Tort reform wouldn't be an issue without jury trials and jury trials are embedded in the Constitution of the United States of America.

Also, the stats in my state (I can only assume that the other states have similar numbers) clearly show that a small cluster of doctors are responsible for a huge percentage of the total malpractice awards. But whenever any state lawmaker suggest making it easier to remove these repeat offenders from the profession, guess who comes to the state capitol to lobby against any change??

 

[plumazul]

There is a very easy way to cut a year or more off the premed process.

Gen chem I/II
Intro Bio
Intro Physics
Calc I/II
Intro Psych
Intro Sociology
Intro Stats
English (what is now called freshman English)
and perhaps a few more, are high school courses that should be taught in high school to high school students.

If high school classes were a little more interesting, maybe more high school students would be interested.