Will medical school as we know it exist in a decade?

A century ago in the U.S.,  the American Medical Association (AMA) created the Council of Medical Education (CME) to evaluate the standard of medical education.

In 1908, the committee recruited the Carnegie Foundation to survey the 155 medical schools operating at the time in order to see whether they met the standard of medical education set by the CME. The Carnegie Foundation in turn asked Abraham Flexner, a professional educator, to create the report. Two years later in 1910, the Flexner Report was released, citing shocking disparities in the quality of education and surprisingly stating that there were too many physicians being educated!

Subsequent to its release, nearly half the medical schools in the U.S. merged or simply closed. A hundred years later, what would Abraham Flexner write if he surveyed America’s medical schools today?

As before, Flexner would have to visit every medical school to survey the conditions present. In the 1910 Report, Flexner’s main recommendations were simple. First, he suggested that every individual entering medical school have at least a high school diploma and have completed at least two years of education at a collegiate level. Second, medical school education should consist of four years, two with pre-clinical education in anatomy, physiology, and pathology followed by two years of clinical education with active participation on the behalf of the students. And third, the medical schools should be run as non-profits under the auspices of a larger university setting as too many were being run by private doctors as for-profit enterprises.

Considering the evolution of medicine, many of Flexner’s recommendations still should be pursued. While it is clear that a high school and college education should be pre-requisites, the content of those pre-requisites should evolve. Do medical students really need to have taken a full year of physics and organic chemistry / biochemistry to succeed in medical school? While some scientific background is definitely necessary, those four semesters may be better spent pursuing either more biology courses or perhaps courses in ethics or business, fields that complement the practice of medicine well. Furthermore, while two years of clinical training still appears appropriate, the overlap and redundancy in the pre-clinical education wastes students’ time. The two years could be condensed into one. While this may seem too extreme, excellent medical schools such as the University of Pennsylvania and Baylor College of Medicine already compressed the first 2 years into 1.5 years; Duke University compress the two years into one! For some students, such as a the presumed MD/PhD neurosurgeon, the extra year would be much more useful down the road either practicing or performing research.

The content of medical education itself must also evolve. Much of what we learn as students has not changed significantly over the hundred years. Given the complex interplay between patients, providers, insurance companies, and hospitals, medical students should have more education about the medical-industrial complex, specifically courses on business, reimbursement, and public healthcare policy. The latter should specifically address what Medicaid and Medicare are and how they function. A graduating medical student’s lack of knowledge on billing, coding, and reimbursement is frankly shocking and often leaves them unprepared for the realities of private (or even academic) practice down the road.

Along with increasing education about the structure of healthcare today, medical education must adapt to the beneficial uses of technology. Many of my peers in medical school did not actually attend class, but would stream lecture videos online to watch in the comfort of their own homes. The benefits were obvious: one could pause to finish writing a note, or even rewind to re-listen to a confusing portion of a lecture. Attendance actually reflected the ability of the lecturer to present material (ie, how entertaining they were) versus that importance of the material being covered. All medical schools should adapt to this reality and provide streaming videos to their students. Furthermore, lectures should be shortened to thirty minutes each in order to force lecturers to focus on the important points within in a topic instead of simply reciting all the known esoteric data on a particular disease entity.

Whether the medical education system chooses to evolve or not is difficult to predict. However, technology shall continue to move forward. If medical education does not, many future physicians will gravitate to other fields that are more “with the times,” leaving medicine looking for its next Abraham Flexner to replenish the once-filled lecture halls of the medical schools of 2010.

Scrub, MD is a recent medical graduate and currently a resident physician who blogs at Scrub Notes.

 

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  • http://drpullen.com medical blog

    The question is whether we still want to graduate students ready to go into any specialty, or start the specialization process much earlier.

  • Vox Rusticus

    I don’t think medical school will change all that much more than medicine itself. Information technology will change the clinical experience inasmuch as it changes the hospital environment. I do not see a change from the hospital to outpatient medicine as a core clinical emphasis since the hospital still offers the richest resource of acuity of disease and treatment.

    The didactic experience will probably change only in that there may be even more resources for learning core material than the live lecture and book reading; that has already happened with many schools providing video recorded lectures. Wider and more convenient distribution of these resources by web portal will improve as medical school libraries become more active as distributors of teaching materials. Some schools may have alternative options to completing core requirements, with web-based courses as options or even requirements. Other core experiences will likely remain unchanged: the gross anatomy laboratory is so much a part of the anchoring experience of the medical student that it would take some unexpected crisis to change or remove that from the curriculum.

    As far as changing the academic course, I suppose it might be possible to separate the didactic/ pre-clinical from the clinical experience, making instead of an M.D. a combined M.Sc. (Physio. Med.) as a preclinical advanced degree, with passage of Part ! as a degree requirement and then a second hospital-based course that might include the final two years of medical school and possibly internship as a different course, possibly allowing one to take the clinical component at another institution. That might require a re-defining of residency as well along with the licensing requirements of housestaff. The only compelling reason I could see to make that change would be to reduce the tuition requirement of the final years of medical school, which has become unreasonably burdensome. I can also see that some residency specialties may once again become academic courses, granting academic masters degrees in course, M.P.H. and Sc.M. degrees.

  • Vox Rusticus

    I really don’t see any other institution besides the university as the center of medical education. Proprietary non-university and non-traditional “university” providers of education are not well-regarded, popular they may be with working people who seek degrees to fulfill work promotion objectives. I do not see a University of Phoenix or Kaplan providing anything more than they do now which is limited to test prep.

    Shifting the preclinical and clinical course to undergraduate schools as is done in the UK and continental Europe would requrie changes in secondary school which do not appear to be coming. Canada might be better prepared to shift to a M.B., B.Ch. style education course than the U.S.

  • jack ga patuto, MD

    i do see the change…..i believe that the traditional training will be of the past.
    the computer age has changed all. i do see getting a medicl degree on line someday.
    may i record this first? the new conception will be “computer doctors”. anyone can apply.
    the “oath” for practicioners will be a thing of the past.
    “virtual” medicine will take over “real” medicine. and, in a real disaster—the virtually taught medical student will be lost…….

    a former dr. without borders…..

  • http://www.cyberdentist.blogspot.com Dean

    When I started dental school, the emphasis was on including more pre-clinical courses to make dentistry more like medicine in education and training. In fact I took many courses with medical students, and studied the entire body in gross anatomy. Thus, the evolution of the degree: D.M.D. (Doctor of Dental Medicine) at some schools. They also emphasized research. We didn’t really touch a patient till the third year. In hind sight, though I enjoyed pathology, histology, etc., I would have liked more courses on business.

    It is very hard to change medical or dental education, “We did it this way, we have always done it this way, so you are going to do it this way too.” As we all know, many “professors” while good clinicians, are very good educators, but some are not. I still remember “teachers” who, after you had spent hours carving a wax pattern for a crown by hand (something dental students do) with no help from the teacher, would look at it, throw it on the ground, crush it with their shoe, and say it was %$&#, and to start over. I suspect some things will never change.