Fixing health care includes reforming medical education

I had a chance to “moonlight” in the internal medicine “drop-in” clinic at the Kaiser Medical Center in San Francisco while I was finishing my residency and endocrinology fellowship at UCSF.  I was superbly trained in in-patient care and there was no IV or PA line that I couldn’t put in with my eyes closed.  I was comfortable taking care of really sick people and thrived on complex, acute cases.  I knew how to work up a VIPoma (vanishingly rare endocrine tumor), but, I didn’t know how to treat a paronychia (a skin infection around the nails) and I was bored silly by colds and sore throats – the run of the mill cases that filled up the Kaiser clinic.  I used to daydream about building a machine that would grab (gently) the patient by the neck, insert a throat swab, and then spit out a prescription for penicillin.   Nine years of training for this!  What a waste of all that training!

Well, it turns out the real waste may have been all that training.  In a provocative opinion piece in the March 21, 2012 issue of JAMAEzekiel Emanuel, MD, PhD, and Victor Fuchs, PhD advocate for shortening medical training by 30%.  Currently, they point out, it takes about 14 years after high school to train a subspecialist – 4 years of college, 4 years of medical school, 4 years of residency, and 2 years of fellowship.   These doctors are now 32-36 years old and deeply in debt. They often feel that they have to make up for lost time and money, by practicing high volume, procedure-focused medicine.  In my opinion, the US approach to medical training has contributed to the mess we are now in.

Emanuel and Fuchs propose that training could be reduced to ten years by shortening pre-medical training to two or three years, shortening medical school to three years and residency to two and fellowship to one.  They point out that many residencies and fellowships have substantial time devoted to doing research, but most doctors are never going to do research.  Those that are aiming for a career in academic medicine could opt for the extra research training, but those with the goal of a clinical career could skip it.  Although anecdotal, it certainly resonates with my experience.  I wanted to be a clinical endocrinologist and had little interest in research.  Nevertheless, my attendings, giants in endocrinology one and all, were constantly urging me to do a “quick and dirty” little study so that I could get a publication.  No wonder our journals are filled with research that really brings no real value to anyone beyond the lengthening of CVs.

So, is there any evidence that reducing time spent in medical training could be done without harming the quality of US physicians?  Indeed, there is.  But first, as Emanuel and Fuchs point out, over the last few decades, “years of training have been added without evidence that they enhance clinical skills or quality of care.”  Conversely, we now have pretty good evidence that shorter training does not lead to a poorer quality graduate or practitioner.

Indeed, most European and British medical schools provide 6 years of training post high school (including both pre-medical and medical training).  In addition, according to the authors, more than 30 US medical schools now operate programs that take only 6 or 7 years post-high school.  Loftus et al, in a paper published in Teach Learn Med (1997) found no evidence that graduates of the shorter programs perform worse on board exams or as practicing physicians.  Further, the authors point to several institutions that have reduced pre-clinical training time, including University of Pennsylvania and Duke.  Again, “there is no evidence that students from either school perform worse on board examinations, placement in residency programs or other significant metrics of competence.”

Emanuel and Fuchs suggest reducing residency training by one year.  The third year, they point out is “not essential to ensure competent physicians.”  I was on the cusp of the change in duration of internal medicine residencies.  Starting with my class, IM was changed from 2 years to 3 years.  I was offered a slot in the UCSF endocrine fellowship, so I took a chance that I would be able to waive that final year.  I was wrong.  I had to go back and put in the third year of internal medicine residency after my fellowship – very painful as my interns were now my peers and my 2 years away from general internal medicine rendered me a bit rusty in clinical areas not related to my fellowship.  I am pretty sure I wasn’t a better doctor for that extra year, just an older one.

By cutting out or making research years optional, both residencies, such as surgery that require a research year, and fellowships that mostly include a research year could be shortened without degrading outcomes.  Docs would go out into practice a bit younger and less in debt.

Now, we all know that change is not easy.  Medical educators and organizations that oversee medical curricula, such as the AAMC, have a vested interest in the status quo.  It will take a fair amount of work to re-engineer training programs so that all of the essentials are included in a shorter training period.  Difficult, yet … but not impossible.  Probably a harder nut to crack is how to provide hospital night coverage if training is compacted.  But as Emanuel and Fuchs point out, “the education of residents and fellows should not be held hostage to clinical service responsibilities.”

As we continue to debate the provisions of the Accountable Care Act and await the decision of the Supreme Court, I think it is reasonable to include reform of medical education in the discussions.  Health expenditures account for more than 17% of the US GDP.  According to another paper by Victor Fuchs (Major Trends in the US Health Economy), we spend more on health care than we do on “all manufacturing or wholesale and retail trade, or finance and insurance, or the combination of agriculture, mining and construction.”  And yet, those sectors are also important to the health and well being of our country and its citizens.  We need to get a handle on this, and that means, in my mind, putting everything on the table including medical education.

Patricia Salber is an internal medicine and emergency physician who blogs at The Doctor Weighs In

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  • southerndoc1

    If a cardiologist, say, is doing unnecessary stints to increase income, shortening her training will only serve to increase the length of her professional career spent racking up big bucks.

    Why do we think we can change human nature, and continue to avoid the obvious answer?

    If we want to pay less for procedures, pay less for procedures (i.e., not at 30-40x congnitive services).

    • jamesp

      HERE HERE!!!!

      BTW, it is spelled, “Stents.”

  • SaraJMD

    Interesting. Clearly, this 2 year training schema would have to involve some redefining of specialties and subspecialties, which, to me, is a good thing. In most countries, physicians are first trained and certified in a sort of general primary care, which ultimately makes sense. Any other training, including something like pediatrics, is over and above that. Even many allied health practitioners in the US are trained in such a schema. It would be harder to complain about the shortage of primary care providers if, essentially every physician could be called upon to do it if necessary.

    After that, we need to get training out of the hospitals to a greater extent to actually train physicians for what most will spend most of their time doing. I think the problem of highly hospital-focused training is the real elephant in the room, given the way we “fund” GME in this country…

    • Abbydoodle

      Your comments are frighting to patients.  You appear to care less about education but do want to make money…..Read the patient boards they are sick and tired of uneducated doctors, assumptive turkeys that think they are god, those who don’t recognize their own limits, those who are caught up in group think and cannot even go to the bathroom without instructions.  We need real, extremely educated doctors.  Not those who want less education and less training.  Heck give us the right to write our own prescriptions and diagnosis.  You make no need for a doctor.

  • jimmyon

    According to the article you reference:  “Another advantage of shortening the length of training would be to focus attention on the essential content of medical training. Changing the structure of training would force medical leaders to eliminate unnecessary and repetitious material and emphasize training physicians to become part of a care team; enable physicians to recognize their limitations as well as their competencies; enable physicians to use evidence more effectively to improve care; and enable physicians to become comfortable with group decision making, standardization of practices, task shifting to nonphysician providers, and outcomes measurement”
    Seems like a less educated physician may be more easily controlled and not question guidelines and protocols.  What an advantage to the central planners, but I wonder if that is an advantage to the patient.

    • ProudOkie

      So more education = increased ability to control and question? I’m not sure that is worth all of the extra money. And, there are other health care professionals who can question and “control” along with you – taking the burden and liability off your shoulders. We have our own patients, take all of own call, and only have physician involvement at the minimum required by state law. We employ them and pay them a fee to meet those requirements. The OPs post is magnificent, reality based, and the future of healthcare and the medical subset. Thak you for the post and the original article.

      Proud Okie

      • jimmyon

        No, more education does not include increase ability to control.  But more understanding of underlying disease process allows more personalized medicine as more variables of the individual are considered.  Guidelines and standardized practice only help the standard patient.  Of course if you have a highly trained physician seeing a complex patient, that physician might be tempted to make a decision about a patient that goes against  standardized practice for the benefit of the patient and that makes the administrative control of the patient physician encounter more difficulty.  If the physician doesn’t have a good understanding, they would likely be more adherent to tratment protocols, therefore more easily managed.  I don’t think that should be a goal of our policy makers as implied in the article.  This really applies to all levels of medical providers.

  • qillower

     I started school in the 70s after Vietnam and did not finish my residency until the late 80s but I am a dreaded specialist.  My field is one of the if not the longest school and has seen a drastic increase in class room time.  From what i have seen schools have veered more into money and how much they can milk the government loan programs. 

    The other major problem I see is just not enough people wanting to become doctors.  Then you have the problem of poor education system or colleges who have dumb criteria.  However cutting internships is a dangerous gamble.  Most medical student fail during internships because of panic and freezing up.  My favorite is the Uh umm huh, deer in the head light looks when I they finally see real head trauma from a car wreck.  Interns need to be trained as best as possible instead of a checklisted.  This is especially important in specialty fields.    

  • robinkjsd

    There are many non-Medical personnel – even some janitors in my experience – who know a LOT about healing and curing. They learn through experience. By being awake and alert each waking day. Some people sleep with their eyes open and, despite exam scores, etc., don’t know much. Some “experts” believe that because they didn’t like something in training or school that it shouldn’t be required of future generations. As my father always would say one can learn from every experience whether it was how to do something or how NOT to do something. Regardless, one learns by having more experience, not by having less!

  • Steven Reznick

    Dr Emanuel is the brother of former White House Chief  of Staff and current Chicago Mayor Rahm Emanuel an architect of the new health care reform plan. They are looking to spend less on education and pay lesser trained individuals less money. This idea is not unlike the dumb idea his brother is espousing to turn Chicago’s Community College System into vocational colleges. I have nothing against vocational training for those not desiring a prep school university level program and looking to learn a trade but the education should be pre college level and it is no reason to ruin the community college option for others. 
    Medical knowledge is more complex than ever before and the technology and equipment and procedures more complex. Medical students spend less time experiencing the different areas of medicine than ever before. They use the third year of medical school to rotate through the different discipline. Then they choose their specialty before they match for internship programs.Gone is the rotating internship which exposed physicians to the decision making trials of their colleagues at the graduate level. The ABIM now wants to have separate and distinct hospital inpatient training tracts and outpatient tracts further limiting new doctors exposure and training. Doctors communicate poorly with their colleagues. I believe it is because they have no idea what their colleague actually does on a daily basis.
    I believe the education needs to be expanded not shortened. We should be screening for candidates who realize that a life in medicine demands 60- 80 hour weeks as the norm. We should be screening for candidates who expect the balance between professional life, home life and personal life to be a constant balancing and juggling act. We should re institute a year of general training for all the post graduate doctors which must be taken BEFORE they can enter a specialty. We should add a year of general service in a national health service corps BEFORE candidates can take additional medical specialty training. We should have the federal government pay for doctors and nurses  entire expanded education if they go into a needed primary care specialty or needed specialty and agree to stay in it for 15 years post training. At the same time we should stop funding in specialties we do not need more practitioners in. These are the changes needed in medical education. Yes we should incorporate early clinical exposure in medical school so that the class room based biochemical and histological and pathological teachings are supported by real life day to day examples of how the book learning effects the care giving. Courses on communication doctor to doctor, doctor to nurse, doctor to patient need to be emphasized along with ethics training. Extra nutrition training is needed as well. Health care reform needs a broad base of strong generalists in medicine and nursing and fewer specialists. The fewer specialists will stay busier as they perform the complex procedures and act as advisors on complex cases setting clear parameters for what should be done and how often, when and if ever they need to be reconsulted.  

  • The Notwithstanding Blog

    British medical training may seem shorter on the front end (6 years post-high school instead of 8 before finishing medical school), but they make up for it many times over on the back end for specialty training (even in generalist fields). Not even close to being “evidence” (much less “good” evidence) that shorter training overall is no different.

  • dsblanchard

    To do what you suggest merely make all nurse practitioners and/or physician assistants primary care providers and all MD’s and DO’s specialists. It would necessitate a change in the content of the nurse practitioner’s education, but it wouldn’t lengthen it. What do you think?

    • davemills555

      BINGO! You broke the code! I love this idea! My PCP always says, primary care isn’t rocket science. He tells me that he’s been doing family medicine for nearly 30 years and he says that about 85 percent of the cases he sees could be easily handled by an NP or a PA. Flu shots, wart removals, cuts and bruises, etc. The other 15 percent usually get referred out to a specialist. All emergencies get referred to 911. So, what’s the big deal? It’s money! Plain and simple. Money!

      • jamesp

        Dave- I have followed your posts for years. I respectfully disagree w/ that opinion-

        If your PCP really believes that, he/she may be in denial about a few things. Rocket science invoves no art- treating people, does!

         I have seen board certified FP and IM Docs who refer most pts to specialists (unnecessarily, IMHO), as well as NPs/PAs.

        Other FP/IM Docs may not refer to specialists nearly as much. As more americans go without insurance (or go on medicaid which is almost as bad as none), the real PCP’s will step up and TREAT their patients. The pretenders (including board certified), will keep referring!

        • davemills555

          Actually, the smart PCP knows his/her place in the world of family medicine and refers when his/her malpractice insurer says they don’t pay claims for “pretenders” that think they are brain surgeons when, in reality, they are really not much more skilled than a NP or a PA. Let’s face it, some docs get way too full of themselves.

  • paul

    Why not just throw out the requirements for US residency training to get a license in the USA? Whyn ot outsource the expensive eduction to the european countries? THat might mean dismanteling the power of the Federation of State Medical Boards and American Board of Medical Specilaties that are now pushing to force physicians to consume their testing and educational programs FOREVER under the guise of the Maintenance of Certification (MOC) and Licensure (MOL) programs now being forced on physicians!

    From:August 2010 29:8 Health Affairs 1461-8. doi: 10.1377/hlthaff.2009.0222
    ABSTRACT One-quarter of practicing physicians in the United States are
    graduates of international medical schools. The quality of care provided
    by doctors educated abroad has been the subject of ongoing concern. Our
    analysis of 244,153 hospitalizations in Pennsylvania found that patients
    of doctors who graduated from international medical schools and were
    not U.S. citizens at the time they entered medical school had significantly
    lower mortality rates than patients cared for by doctors who graduated
    from U.S. medical schools or who were U.S. citizens and received their
    degrees abroad. The patient population consisted of those with
    congestive heart failure or acute myocardial infarction.We found no
    significant mortality difference when comparing all international medical
    graduates with all U.S. medical school graduates.

  • Alieta Malwitz Eck

    So-o-o, while Dr. Emanuel thinks we should shorten medical education, the ABIM and other Boards want to add to it in the form of more extensive maintenance of certification (MOC) and even MOL.

    While the ABIM is on a mission to have us order less tests, the ABIM wants to increase testing on physicians. There is a disconnect in logic. Do we need more education or less?

    This seems more about saving money on one hand, but extracting more money from practicing physicians on the other hand.  It has little to do with evidence that more or less is better, especially in the realm of MOC and MOL.

    Alieta Eck, MD
    President, AAPS

    • medocadvikian

       It’s more about power than safety. Organizations want to control individual practitioners.

  • Abbydoodle

    This article is very frustrating at best and at worst angering.  As a patient that has spent 44 years of my 56 year old life trying to figure out what was wrong with me and having to fight the education of doctors all the way….if only they had ben CORRECTLY educated, I would not have the collateral damage I have now.  And note my my spent the first 12 years searching, I joined in when I could intelligently speak to my GP and specialists.  The answers to all my questions were already documented in scientific papers over 20 years old.  Yet the well educated doctors had not even read them nor been made aware of them.  So from age 21 to 54 I was constantly misdiagnosed and mistreated.    It was my own dumpster diving into medical databases that defined my disorder and diseases.  One joke, I found a UK diagnostic database –I entered my symptoms and lab tests and it correctly diagnosed the root cause.  Armed with this I went to specialists who still required biopsies and extensive lab work to confirm what I already knew. Now I teach at a local university about my experience and how to recognize my disease/disorders to budding doctors.  I have been told by doing this several lives have been saved.

    The patients were not saved by too much education in medical books–they were saved by a patient that had the strength and means for feedback and education of medical personnel.

    Your supporting less education and agree with the fact that doctors have been manipulated by HHS to cut diagnostic texts will put patients in more danger of dying.  Your ideas will not save lives…shame on you.

    The patient advocy groups I am involved with that also include doctors on the panels also advocate more education for doctors and the public.   I have been researching medical books and teaching tools in the past year and find that almost all fail to educate the medical student about the facts of my disorder and diseases even though the medical field has been avidly treating it since the 1970s and before.  Also, the government uses a description written by a doctor in 1973 which also fails to including research findings from 1990 including the facts that the genome project and other gene projects have revealed as to why certain pathways fail and the disorder affects multiple organs, multiple pathways, the mitochondria, central nervous system and the autonomic nervous system. Most medical documents only adress one pathway and treatments related to it.

    Medical education has fallen into a severe situation because it is treated within silos of information with no cross communication from other silos.  Thus our doctors are less educated than in other countries in some fields.  You state you were bored.  Poor pitiful you.  If you did not want to do a job then get out of the field.  Do you know the ER is one of the first places that people with my disorder show up.  Doctors in almost 99% of the cases for adults misdiagnose it.  So if you had had a broader education you may have saved a life that you never even knew that you ultimately ended by saying a person had the flu and it was not.  Too late if that person goes into a coma and dies later.  I know of multiple cases where this has happened.

    A group that I was with last week spent time discussing how to deal with educationally challenged physicians and specialists.  We have to bombard them with scientific studies, results, and patient case studies just to save our own lives….Doctors have come to rely on lab tests as the gospel so if it says no even though the patient has fever, over 20 areas from blood tests way out limits, they still turn their backs.  Leaving families grasping and turning to online societies for help finding treatment.

    Your comments are truely devestating to many people in the United States….lets lower the education standards because you were bored.  BS you should not have been allowed to graduate until you knew more that you obvisously stated you did not.  And of course it is very difficult for patient to sue for an uneducated doctor.  At least I have had the joy of having a few reprimanded and loose their position after they made inane, uneducated misdiagnosis that put me in a life threating phase.   If only they had use the website RightDiagnosis they would have done a better job.  I don’t know where you are most dangerous–writing articles that suggest ideas that harm and kill patients or actually practicing in an ER bored to death and missing the proper diagnosis and thus along the way the patient dies.  Either way your ideas are quite harmful from a patient’s part of view.

    Until we can have some type of continuous testing that the public would know the results as to the educational strengths and weaknesses of a physician —one should not be allowed to cut education nor diagnostic testing.  To ‘H’ with the inconveniance to the student.  You are there to learn and should have the initiative if you are bored, to study even further. 

    I do not see this about power.  I see this about reality and treating patients.  Maybe your grades for each course and GPA should be public knowledge as well failures during medical school.  Patients should have the right to know if the person taking their money really is sufficiently educated.  I do not see anything in your article about dropping fees  because you are less educated…

    • jamesp

      What???   ALL that polemic and not ONE mention of the disease you actually have???

      You insult an insightful piece by an apparently thoughtful, caring physician, and you can’t even be bothered to SPELL correctly???

      I smell BS!

      • Abbydoodle

        I can spell this DF.  I have been in a coma and have suffered brain damage because of my disease.   Stating the truth is not insulting.  Obviously you do not live in the real world with patients with rare diseases who have to deal with the plethora of ignorant staff –totally uneducated.  It is sad that we constantly have to care information packets about the disorders, root causes, treatments, emergency response protocols, medications that cannot be taken or they can kill any person with this disorder.  Just yesterday I conversed with another family where the doctor misdiagnosed the baby at birth.  Three days later the baby is dead.  There are tests that can be run at birth and would have saved the child—but no they are not run.  THEN IGNORANT UNEDUCATED medical staff MISDIAGNOSE and there is DEATH.  So insult?  If I can pull back the layers of ignorance and misinformation to save lives then I have done what the doctor has failed to do upon taking their oath “first do no harm”.  Do you believe less education means do no harm  –Ha get real.  And note this James.  I now teach every year at a research medical school to insure the metabolic genetic students are aware of a certain group of diseases, what they look like manifesting in adults –after a stupid 50 years of doctors being taught that they only occur in babies.  I also discuss treatments that can keep a patient alive.  My activities has saved multiple people who during the past 7 years came into ERs in several large hospitals and the lead doctor was stymied and they deemed nothing could be done the patient would die and left them to die.  Students turned residents recognized the symptoms on grand rounds and within 30 minutes labs proved the diagnosis (that is all it takes 30 minutes!!!) and then within the next 30 minutes the patient was given the correct medicine.  All of the women lived.  I have received special recognition for my part in saving lives.  As for my disorder, who the hell cares?  It is education we are talking about.  Education in total.  It is time for the old gods to realize they do not know everything but need to always continue to learn!!!  If I found out I had a doctor that had cut medical studies –Oh wait I found one that called himself an infectious disease specialist with only 6 months of studies. —Yes I was able to confirm this monster who could have killed me was not qualified to treat me and let the University president know in no uncertain terms what the doctor had tried.  I went to someone else only to discover that I had an ear infection that had spread quite extensively into the bones of my head.  I spent many hours in surgery while my disorders caused even more problems.   You want to know what I have?  I have ornithine transcarbamylase deficiency with disorders to the brain, thyroid, dysautonomia, uncontrolled body temperatures and sweats–so much so that threat my life at times, seizures, tremors, muscle constriction —all because my OTC also damaged the mitochondria in my body.  If you read the correct scientific papers it damages the portals, complexes I, III, and proton pumps.  But they do not teach in medical school that OTCD is not just a urea cycle disorder but also a mitochondrial disorder.  In fact many text books eliminate where the Ornithine Gene is located as well as what happens when the process ornithine transcarbamylase in the mitochondria is damaged —except to what it does by causing a deficiency in ornithine that impacts the assimilation of protein during the Krebs and TCA cycles and leaving ammonia to build up.  It is that ammonia that the body cannot eliminate.  Ammonia is a neurotoxin –build up causes nerve and brain damage as well as the disorder damages the the thyroid, heart, liver and more.  Patients with this disorder can develop NASH and diabetes.  Women have miscarriages and stillbirths as well as both non affected and affected children.  I have had mine since birth.  My mom saved me with sugar water while the doctors told her it was milk allergies –yep another misdiagnosis.  But a mother’s intuition saved her child who has a very high IQ and is not an arrogant fool like some people that defend uneducated, unqualified doctors!  I have a research library that is very indepth and also receive genetic and metabolic research on a daily basis.   I will go back to saying anyone that wants to cut education for the glory of the dollar is stupid.  We patients cannot afford ignorant doctors.  Yet the doctors see nothing wrong with it?  Where are the morals? Where are the ethics?  Where is the “first do no harm”?    Just because a doctor has a degree does not make them caring and knowing.  And James as your history shows, you spend quite a bit of time attacking other posters but only add bovine excrement otherwise.

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