Arthur L. Caplan, PhD: Hi. I am Art Caplan, head of medical ethics at New York University (NYU) School of Medicine. I want to welcome you to Medscape's ongoing series, Both Sides Now.
Today, we are going to look at a novel and controversial approach to medical training. How long should a doctor go to medical school? How long does it take to learn all that they need to know in order to become a good doctor and provide the best care?
3-Year Versus 4-Year Medical Schools
Dr Caplan: As many of you watching this know, most medical schools have a 4-year curriculum. A small number have started to offer an accelerated 3-year program. Some say that this is a good way to attract more people into the medical profession, prevent physician shortages, and reduce crippling medical school debt. The American Association of Medical Colleges estimates that it costs $278,000 to attend a private medical school. Others say that students will get an inferior medical education without enough time to learn, digest, and get the experiences and confidence they need to become a good doctor if they are not doing the 4-year curriculum.
A number of 3-year training programs have been launched, including those at Mercer University in Georgia ; the University of California, Davis ; Texas Tech ; and my own school, NYU. Today, we have two guests who can shed light on the pros and cons of this change in training. Dr Stanley Goldfarb, professor of medicine at the University of Pennsylvania in Philadelphia, feels that medical school curricula should remain 4 years. Dr Steven Abramson, vice- dean at the NYU School of Medicine, is at a school where a 3-year curriculum is currently being offered.
Thanks for joining us, and thanks for being on the show. I have to confess to viewers: I know these two physicians very well. It is a real pleasure to have you both here to discuss this issue.
3-Year Medical Schools: The NYU Perspective
Dr Caplan: Let me start with you, Dr Abramson. Can you really fit clinical training and all the learning required into a shorter time frame?
Steven B. Abramson, MD: You can, if you think of learning to be a physician not as a 3- or 4-year period, but as a 6-, 7-, or 8-year process. Medical school—the MD degree—is one journey and one point along the journey. Then doctors do 3 years of residency, or longer for certain disciplines. If you specialize as a fellow, your training may take 7 or 8 years, if not longer. One can conceive of learning to be a physician as an 8- or 9-year journey. Therefore, things that you pick up along the way can be applied to your practice. Although the foundations of medical school are very important, if you ask doctors about their everyday skills and the knowledge they apply to what they do, it is often more from their last several years of training.
Dr Caplan: Do you teach the same courses [for both curricula] at NYU, or are they compacted into less time for [the 3-year curriculum]? How does it work?
Dr Abramson: No. We have modeled it so that the first 3 years are the same, no matter what pathway you are on. Students cannot accelerate or decelerate along the way. Basically, the difference is the fourth year, in which students enter an internship. We had an epiphany that we were trying to get a masters of public health (MPH) degree integrated to our MD degree, and rather than have an extra year (typically 5 years of training; 4 plus 1), we realized that we could get an MD /MPH in 4 years total. We looked at the board and said, "Geez, if you can do your MD in 3 years and then get an MPH, what else might you be able to do at the end of the fourth year?"
Dr Caplan: Do they go more during the summer or over holidays?
Dr Abramson: No ; basically, it is the same.
Dr Caplan: How do you admit people to the 3-year program? Do they self-select? Do you recruit them?
Dr Abramson: They self-select. If they are accepted to our medical school, they are given the option of applying for the 3-year program. About 10% of the class will apply. Who are they? They often are students who already have been out for 1 or 2 years. They often have a MPH, master's degree, or PhD. And they think they know what they want to be. We interview them, and the residency programs interview them, and then 10 or so are selected to fast track. Surprisingly, of our initial cohort of 16, I expected one third of them to change their mind and drop out. All but one stayed in the program, and we graduated our first class last year.
Because of criticism that these kids would not really know what they wanted to be, in the last 2 years we have had an "opt-in." After the first year of medical school and then after the second year of medical school, students can decide to accelerate and graduate in 3 years. We cannot meet the demand. About 25% of the class is now interested in opting in to finish after 3 years.
Cons: 3-Year Medical Schools
Dr Caplan: Dr Goldfarb, you have some reservations about this. What cannot get done in 3 years that traditionally takes 4 years that concerns you?
Stanley Goldfarb, MD: We wrote a paper about this in the New England Journal of Medicine a few years back addressing whether this could be applied broadly. It can be applied to certain students. The student who has been out in the world for a few years and has a clear idea of what he or she really wants to do with their life certainly could be a candidate for this.
The other problem we had with it, which perhaps was solved by the particular approach NYU has taken, was the fact that when this was tried back in the 1970s and 1960s, it was almost universally felt to be a failure, in part because both students and faculty felt the pressure. The students went during the summers. It was 3 straight years, and it was very intense.
This is a time of worrying about physician burnout and student burnout, as well as faculty [burnout]. Ohio State [University] did a careful analysis of the faculty's satisfaction with this. They also felt that the students had not learned enough and were not well prepared.
Our view was that this might make sense for a certain selected group of students. I think that is the way it has played out pretty much at most schools; it has been a cohort. In some schools, it is a few students, and in others, as many as 10% of the class has been in these programs.
Dr Caplan: Do you think the knowledge explosion, even for the self-selected, undercuts the idea of a shorter curriculum?
Dr Goldfarb: That is an issue. To be supportive, studies have attempted to compare students coming through 3-year curricula with 4-year ones. For example, McMaster is an excellent 3-year medical school, with 200-some students per class. When they were compared with 4-year graduates, they do as well on exams and seem to be at the same point. It is doable. It is quite correct that physicians are studying not only for those 9 years, but for their whole lives.
On the other hand, you cannot do it for everyone. A good example of this is the fact that about 40%-45% of students coming in to the University of Pennsylvania Perelman School want to be pediatricians. But fewer than 10% end up being pediatricians. That is a huge problem. How do you create a mechanism where everyone can get into the field that they really want? They change their minds.
It is an issue, and it is going to be too rapid, too intense, and too short a period for some students, and they are going to feel stuck in this particular pathway.
Do 4-Year Graduates Outperform 3-Year Graduates?
Dr Caplan: Do you have any notion that the first graduating class from NYU is less well-prepared, and more burned-out? Are there any significant differences between them and the others?
Dr Abramson: No ; they appear to be indistinguishable, which in many ways does not surprise me, because they get the same core. Fourth-year students, especially if they are applying to competitive residencies, often spend 40-50 days visiting and applying to other schools. In fact, we did an assessment of knowledge and skills in March for the 30 kids who were graduating after 3 years and compared their performance with that of the graduating 4-year students. The 3-year students actually outperformed them in simulation studies because they were just coming off the experience.
The real question is: What happens at 6 months and 12 months? We have this first experience. It is very interesting. We have about 18 different programs, which is also what makes NYU a little different from some of the other places.
The kids are performing just as well. They are indistinguishable from the other 4-year residents. What surprised me the most, the groups that I thought would be taking the biggest risks were the procedure-oriented neurosurgeons and the orthopedists. They took these students without seeing whether they were clumsy.
A lot of medicine is socialization and what happens when they go on the clinical wards. They do not only learn medicine, but they learn how one should behave. That has pros and cons. People talk about the so-called hidden curriculum and the bad lessons they learn. These kids hit the ground [running], having been part of the department. Our most avid supporters, surprisingly, are the neurosurgeons, plastic surgeons, and orthopedists.
It was not until we were doing the 5-year programs that we met the 4-year MD / MPH, which some schools have.
Dr Goldfarb: A study out of the University of California in San Francisco asked program directors about the students whom they sent to those programs. They asked them how well they were prepared. This is now a 4-year school. They looked at students in a variety of specialties. These students are among the best in the country in terms of their performance on standardized tests and so on.
The program directors evaluating those students thought that about one third of them, 27%, had insufficient medical knowledge, and 33% lacked organizational skills. Another one third lacked the traits of professionalism and humanism that they like to see. What I took away from this is: Yes, you could do this. It is possible. You can do a lot of things.
We need to do better with the way we are training medical students. A key to that is the fourth year. The fourth year needs to be enhanced and strengthened. Yes, we have a lot of 5-year students. I think almost 40% of our class has done something besides the 4 years, including a very large number having an MD /PhD, certificates, or second degrees.
Challenges: Cost, Residency, Maturity
Dr Caplan: Should medical education be cheaper? Should we try to get to 3 years, not just because of content, but because it is so expensive?
Dr Abramson: That is a good question. One of the reasons that we thought 3 years could be advantageous for some was this real debt crisis. The average debt is around $160,000-$170,000. More important, some students carry $300,000 worth of debt. I do not think the solution for that problem is a 3-year medical school.
Other villains in this picture are the residency programs. The numbers of applicants have skyrocketed. Part of the reason the [number of] applicants has gone up is not the number of graduates per se, but the numbers of programs that our graduates have to apply to in order to get admitted. That puts them on the road a lot. That is another structural problem.
Our reason, frankly, was that medical school has been 4 years going back to the early 1900s. What has changed since the 1970s and 1980s is the length of training after medical school—when board certification came in, and you had to pass these boards.
Dr Goldfarb: The millennials are a very interesting generation. There are wonderful students, but some are not quite ready to take on the responsibilities that are entailed by residency when they are 20 or 21. They may have difficulty making decisions about how they really want to spend their lives and what commitment they have to medicine. For example, do they want to be trauma surgeons who are on call 3 nights a week, or do they want a field where their time is much more shift-based? These kinds of decisions about how they want to spend their lives are very hard for them to make that early.
Dr Caplan: Do we need a warm-up period before going to college?
Dr Abramson: We are all subject to our own biases. College, especially if you are going to be a physician and you learn about things other than medicine, is a very valuable lifetime experience. Like everything else, people are different. That is an evasive answer.
There was a very important article in JAMA that Emanuel and Fuchs wrote in 2012 that caught our attention. It basically said that shortening medical training by 30% would not affect the outcome. They said it could be in college. It could be in medical school. It could be in graduate medical education (GME). They challenged that people should think about this. We chose to look at the medical school piece.
As a former director of rheumatology and fellowship director, I know there is a lot of fat in GME, in fellowship training, meaning research years for kids who will never do research. There is a lot of training that one could take a hard look at. If you are going to be a clinician in field X or Y, do you need that second year of fellowship to be in a lab or to be doing some investigation? It is a complicated answer. The point I am making is that we have to look at each of these segments.
Does This Address the Doctor Shortage?
Dr Caplan: I am going to ask you two more questions ; Dr Goldfarb just hinted at one of them. Aside from money and tuition burden, there are apparently person-power issues, manpower issues, coming up. Are we going to have enough docs? Are we going to have the right docs? Is there a role here for the government to say, "If you do the 3-year track and you become X, then maybe we will throw you some money and speed up the process. We have to get some more docs out there." Is this a place for engineering?
Dr Abramson: Should the government be loan-forgiving for people going into unmet areas? It is interesting. Graduating students in 3 years does not add more docs, because you reach a steady state. What we have argued is that you get an extra year of a doctor's work—maybe some 200 surgeries or some 500 patients seen.
Dr Caplan: Is that how you see it?
Dr Goldfarb: Every specialty society has identified huge deficits. Oncology is one. Everybody would agree. You would really like to make sure that there is an oncologist that can see you whether you have cancer and need chemotherapy pretty quickly. The deficit in oncologists, no matter what scenario you pick, is really quite frightening when you look forward.
What Makes Curriculum More Meaningful?
Dr Caplan: You are a czar of medical education for the United States. What would you change to make the curriculum more meaningful? Would you do something about that fourth year? Would you try to accelerate the number of folks who get admitted into the 3-year programs so that the residency slots were there for them? What would you do if you could wave the magic wand?
Dr Abramson: There are so many answers, but to me the critical need right now is to create what one would call a "continuum of education" between undergraduate medical education and GME. Right now, you get your degree and then go off to another environment, sometimes at your own school, sometimes at another school. Competencies for medical students, so-called "entrustable professional activities," are different from milestones looked at during internship, in part because they are different disciplines. We do not have enough ability to think about this as a single training.
Dr Goldfarb: We need to do a better job training medical students. They need to be better educated when they leave medical school. Most medical errors that are produced around the world represent misdiagnosis. It is not cutting off the wrong leg. It is actually making mistakes in the care of patients. I think our education system needs to be strengthened. It is on us as well. We need to do a better job. We need to put in a much stronger fourth year. We need to make sure that our students are really prepared to be 21st- century physicians.
Dr Caplan: Let me thank both of you for being here. You gave us some great ideas about how to think about reforming and changing what we are doing in medical education. It is much appreciated that you took the time to do that with us.
What is my takeaway from this interesting discussion? I think major curriculum change is in the air, and we are going to see more of it. It is likely that more schools will experiment with a 3-year curriculum. It is not for everyone. As our guests pointed out, not everybody is going to flourish in a 3-year curriculum. There will certainly be schools that do 4 years, and maybe longer periods of training.
At the end of the day, the 3-year curriculum is not really the solution to the high cost of medical education. If we are going to fix that problem, it will have to come through government subsidy, philanthropy, gifts, and other solutions.
The 3-year curriculum is not the answer. It is the answer for some students who know what they want to be and know what specialty they want to enter. They can get there faster and move more quickly down the road of training by having that option.
I am Art Caplan. This is Both Sides Now. Thanks for watching.
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Cite this: Arthur L. Caplan, Steven Abramson, Stanley Goldfarb. Should Medical School Training Be Reduced to 3 Years? - Medscape - Jun 15, 2017.