05.03.2015
by J. Duncan Moore, Jr.
Contributing Writer, MedPage Today
Image from MedPageToday.com
In response to complaints that medical education costs too much, takes too long, teaches the wrong things, and distorts the physician work force, schools are reconfiguring themselves in a variety of ways — with revamped curriculums, new teaching styles, individually shaped courses of study, and shortened study periods.
A handful of medical schools, notably Mercer University in Georgia, University of California at Davis, and Texas Tech, are allowing students to complete their course of study in three years instead of the traditional four, with the expectation that they will go into primary care specialties.
Robert G. Frazier, MD, would like to sound a note of caution, however. A three-year program carries with it definite hardships and some losses that might not manifest themselves until later. He went through medical school during a previous period of academic compression, and he doesn’t recommend it.
“You lost the opportunity to take any byways, other kinds of experience that might or might not be of value,” he said in an interview. “I had plenty of positive academic experience but it had to all be focused on your medical training.”
The period he is speaking of were the years 1943 through 1947, when World War II overturned many conventions of medical training. Frazier, who turned 92 in April, recalls that the war effort governed every aspect of his life for almost a decade, starting in 1939, when he entered the University of Chicago as an undergraduate at 16. “You could see the war crowding in on everything. All of us had to pack in as many courses as we could to try to get admitted to medical school before our draft numbers came up.”
He was inducted into the Army in 1941 and was considered a promising candidate to go to medical school. He obtained a bachelor of science degree in 1944 and a doctor of medicine degree in 1947, all from the University of Chicago.
“All that experience was done without benefit of either vacations or time off for any special training or educational experience,” he says. He remembers it as exhausting.
The intensity of the academic and clinical training that Frazier endured was necessitated by the national emergency of fighting a world war on two fronts with limited resources and insufficient manpower.
Today, medical students and faculties face a different set of challenges. Student bodies are far more demographically diverse. Educational expenses are much higher, and the Army isn’t footing the bill any more. Too many medical graduates are going into rarefied specialties, for a variety of reasons (not least their student loan debt) and too few are committing to careers in primary care. And the practice of medicine has changed in some fundamental ways that medical schools haven’t caught up with yet.
To “close the gaps” between the way physicians are currently trained and how health care is delivered, the American Medical Association has given $11 million to 11 medical schools to test out some new paradigms.
In mid-April the AMA hosted a conference at Oregon Health & Science University in Portland for the 11 schools in its consortium, called Accelerating Change in Medical Education. “We’ve been getting together every six months to share problem solving,” said Susan Skochelak, MD, the AMA’s vice president of medical education. “We went to Oregon to see what they’re doing with their new curriculum.”
OHSU students are finishing the first year of the school’s “competency-based” course of study, which teaches them how to search out data and use information systems to care for individual patients and populations. Once they master certain milestones of learning, they advance to the next level. That means some students will complete medical school in less than four years.
This is the direction medical education needs to go, said George Mejicano, MD, a professor and dean at OHSU medical school. “We have cutting-edge technology, portable health care data, global online collaboration, dramatic new research discoveries, personalized medicine and comprehensive health care reform to support a culture of innovation,” he said. “It’s time for medical school curricula to catch up.”
At another AMA grantee, UC-Davis, the goal is to get primary-care physicians into the field in less time. The curriculum eliminates summer vacations, electives, and the residency search.
Mercer University School of Medicine in Savannah, Georgia, has developed a three-year curriculum for students who commit to family medicine. Texas Tech University has a similar program geared to family practice.
Still, some educators worry that three years might not be enough. Medical school isn’t just about cramming a lot of facts and protocols down the students’ throats. It’s also about the “maturation of the individual, of ideas, of a professional identity,” said John Prescott, MD, chief academic officer at the Association of American Medical Colleges. “All these things take a certain length of time.”
One thing that is not in question is the requirement of accrediting bodies that students receive 130 weeks of medical instruction. These three-year curriculums can easily encompass the full 130 weeks. But any extras tend to get sliced off.
While some academic experts, such as Fitzhugh Mullan, MD, at George Washington University medical school, point to the World War II years as evidence that “we can train excellent physicians in three years,”others are less certain.
Prescott told MedPage Today that after the war, medical schools reverted to a four-year course of study. “There was a general consensus that they had compromised standards during the war,” he said, adding, “My dad was there, but I wasn’t there.”
“You were asking people to do a four-year curriculum, without much of a change in the content, in three years. You were asking faculty, which had been cut by a large number of folks who were in theater (of war), and taking care of casualties, to also teach medical students in this accelerated program. The students themselves were not at the highest standards for medical students at the time. The combination of those things, people said, ‘We are going to have to take a long hard look if we were to change the paradigm.'”
What is needed today, Prescott continued, is a fresh approach to medical education that takes into account all the new self-directed learning tools and resources that have evolved in the past 20 years. “It isn’t so much learning all the material — it’s learning how to use all of it, how to best think through material. We’re looking for students who can best do that.”
At the AMA’s Oregon conference, the theme was “the science of health care delivery,” Skochelak said. “We know physicians are learning deeply about biomedical issues, how the body works, genetics, the clinical sciences, how to make diagnoses.” Now, instead of delivering lectures on patient safety, many of the schools in the AMA consortium are putting 30% of their curriculum on finance, team care, how to work in the system, she said. And the students told them the new curriculum is worthwhile.
“We’re calling it the third science, with biomedical science and clinical science,” Skochelak said. “If you put all these topics together, they really are a science of how you deliver medical care. It’s a body of knowledge, it’s not little pieces.”
Skochelak remembers that when she was in medical school, some 30 years ago, there were some three-year programs. What’s changed recently is the make-up of the entering class.
“About half of our students come into medical school now having done something different,” Skochelak told MedPage Today. “They’re not coming right out of college. They might have been in a health profession, they might have been physician assistants, or teachers. They know how to sit down and work through.” A more flexible learning program lets those students pass out of a required basic science or biology lab if they’re already fluent in the material, and focus instead on what they don’t have.
She doesn’t think a shortened course of study would have any effect on how well prepared a medical graduate would be for a residency program.
For Rob Frazier, though, the compression of his medical school experience played out in unexpected ways over the course of his career. He ended up practicing as a pediatrician for only a short time: two years as a resident, two years as a fellow, and two years as an assistant professor. Soon he went into medical administration, becoming the executive director of the American Academy of Pediatrics from 1967 to 1980, and after that an associate dean at Loyola University medical school.
From the vantage point of 70 years later, he thinks the intensity of the medical school experience in those years probably decreased his enjoyment of the practice of medicine, and made the transition away from it more attractive than it should have been at that point in his career.
Stuffing too much education in too fast “diminishes your capacity to enjoy as many aspects of your own self and interests, your self-development, as you can,” he said. “I think the medical experience is sufficiently demanding that you feel as though you’re letting an educational program sort of short-circuit your life.
“The major problem was, the time was not your own,” Frazier said. “You couldn’t do three-quarters of a year in regular coursework and then take a quarter to do special research or take different courses outside medicine or inside medicine. To me it was the lack of opportunity to control your educational experience that was most frustrating.”
When he looks back on his university days for “at least one peak experience,” he finds it was not medical school. “It was the four-year college.”