Should medical school be shortened by a year?

We have been training physicians the same way for a century, ever since the famous Flexner Report of 1910. That report was commissioned by the Carnegie Foundation in an attempt to improve medical education. Up until then many medical schools were simply terrible. Many were proprietary schools, owned by doctors and run for profit rather than education. Many doctors met their first actual patient after they graduated.

During the decade following Flexner report these proprietary schools either closed or merged with universities, becoming the institution’s medical school. Within a fairly short time the model of medical school as a four year course divided into two preclinical years (studying basic medical science) and two clinical years (learning to treat patients) was the standard. We’ve been doing it that way ever since.

There have long been calls to change this. Various schemes have shortened the usual eight year process of four years of college followed by four years of medical school, usually by shortening the college part. A recent op-ed in the New England Journal of Medicine renews the call for shortening the process, this time by making medical school three years instead of four. A counter-point essay follows, arguing to keep medical school at four years.

What do I think? I think the arguments for shortening medical school are beside the point. Two of the main reasons the advocates give are to reduce student debt and lengthen the useful practice careers (by one year!) of doctors. The latter, they write, would improve the doctor shortage. But really, if the problem is student debt, there are many direct ways to address that. Likewise, if one thinks we need more doctors, then train more.

I think we should keep medical school at four years. There is already far more to learn than can be learned in that period, so shortening things would only make it worse. There is also the maturation factor; to function as a doctor you need how to think like one and act like one. That takes time — I’m still learning at age 61. Lopping a crucial year of the process is not the answer.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must FaceHow to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • babdoc

    I have also heard the argument that there is superfluous information taught in medical school, much of which is four gotten soon after the test is taken. Another argument is that much of the information is repeated multiple times during the didactic years. I don’t buy either argument. A wealth of knowledge is a hallmark of a physician, and decreasing the required information we are exposed to is a mistake. As for that second argument, repetition is useful and important in education. So, I agree: keep medical school at four years

  • buzzkillerjsmith

    Jamming it into 3 years would make for a pretty lousy 3 years. Jamming it into 4 years in no picnic. And there would be more pressure to choose a field earlier. Are they trying to give med students the bum’s rush into primary care, fooling them before they know what’s what?

    My paranoia and cynicism are not getting any better.

  • Margalit Gur-Arie

    The NEJM article is a bit strange. The last paragraph seems to contradict everything preceding it… and the statement: “We need to address the ways in which physicians …. serve the country’s needs, while delivering culturally competent care that reduces health disparities” is a bit peculiar. I think most people want a physician who serves their own personal needs…

  • ninguem

    We went through all that in the 1960′s and 1970′s. Three-year medical programs were tried. Mostly they’ve gone back to four-year programs, switched back in the 1980′s.

  • buzzkillerjsmith

    I was in a 7-year program at UC Riverside-UCLA called the Biomedical Sciences program. They got rid of the 7-year track a few years back. We did 3 years of undergrad and 4 years of med school. They threw a bachelor’s degree at us after year 4.

    This program saved me some money (which I have subsequently lost and then a million or three by going into primary care) and I’m really glad I spent the 4 years in med school rather than taking Social Theory of Patagonian Literature or suchlike in year 4 in college. Four years is not too much med school.

    • Chris Johnson

      For myself, I think the 4 years of college was important. I majored in history and religion, and I think it made me a better physician. But that was in 1973, and I don’t think many go that route these days.

      That 4th year of med school is a bit disjointed, though. You’ve got some easy electives if you want that. But as heartdoc pointed out upthread, if you’re shooting for a competitive specialty or program you need to impress people, and that takes work.

  • Mengles

    First it’s let’s decrease the years in residency (Ezekiel Emmanuel) and now decrease the years in medical school? Geez, I wonder why?

  • Deceased MD

    I hear we’ll be replaced by robots in a few years, so medical school training may soon be obsolete anyway.

  • Tiredoc

    I was a Biology undergraduate major at a school which featured a gross anatomy course. My first year of medical school was a largely a repeat of upper level undergraduate work, only taught less well and by a team of teachers in larger classes for a much higher tuition.

    The only thing that the first two years of medical school does is support the medical school administration. The entire basic medical science curriculum could be dumped in favor of just passing the USMLE Part I test, then applying for the clinical rotations.

    • Chris Johnson

      But I think your experience is not typical. For example, the year of biology I took in college was all cellular, and I didn’t even major in a science.

      • Tiredoc

        I was a biology major. The 300+ level classes that I took included Embryology, Human Genetics, Biochemistry, Microbiology. As I had taken graduate level Biochemistry and Embryology I tested out of those classes. With a slightly different course load, I would have tested out of the entire first year of medical school.

        At my school, you could schedule a 12 week elective “clinical” course between 1st and second years, thereby making the 4th year of medical school consist of a single 12 week elective. If I had done both, I would have essentially skipped the first and fourth years of medical school. It still would have lasted for 4 years and I still would have had to pay the tuition.

        Medical school admissions is a process by which a school selects the top 1% of test-takers in the country and then has them take a test in which most of them pass, then throw them at patients and hope for the best. Without the 1% filter, the weaknesses of the actual training process will become quite obvious.

    • morebuzzkills

      Yep! I think the ideal trade-off would be to take the MCAT which would allow you to achieve admission to medical school. You would pay a minimum “support tuition” during the first 2 years because we all know that schools are not going to completely give up the cash cow of the first 2 years. During the first 2 years you study however you see fit for each course (read textbooks, watch Youtube videos, study with friends, etc). You then take NBME subject exams at specific times. Finally, you study for USMLE Step 1 and enter clinical rotations after you take it. In my experience there were video lectures and texts available on the internet (free as well as fee-based) that far surpassed the quality of lectures at my school. As it stands, the only real incentive for most students during the first 2 years is doing well on Step 1. Unfortunately, this incentive is misaligned with the stated goals of many medical school administrations. They spin their wheels coming up with new buzzword ideas and then spend a lot of time and money presenting them as being effective. If you cut out all the fluff, the first 2 years could easily be shaved down into a year and a half, perhaps even less. Medical education, much like our healthcare system, is fragmented, broken, and characterized by a lot of misaligned incentives.

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