Medical training is lengthening as students increasingly take gap years before and during medical school. Excessively long training times contribute to many problems. Trainees show high rates of burnout, depression, suicidal ideation, and alcohol abuse. Crippling student debt, compounded by the opportunity cost of not earning a salary, make it difficult for under-resourced individuals to enter medicine. Not earning money for a minimum of eight post-secondary years and, instead, paying for living expenses, college tuition, medical school tuition, MCAT preparation, gap year expenses, medical school applications, and USMLE Step 1 preparation are an insurmountable economic barrier for many. Such investments of money and youth also exacerbate the physician shortage in underserved areas.
Simultaneously, students are forced to study the same concepts in chemistry, genetics, molecular biology, biochemistry repeatedly throughout high school, college, and medical school, despite already knowing the material. Why must every student fulfill one-size-fits-all requirements during premedical and preclinical studies, regardless of background or aspiration? An MD/PhD surgeon specializing in tissue engineering does not need the same preclinical classes as a family physician who majored in history.
That a number of medical schools (e.g., Harvard, Duke, Vanderbilt, Michigan) have shortened the preclinical training time from two years to one is evidence of redundancies between premedical and preclinical curricula.
It is possible to condense all of the basic science into one year only because students had prior exposure to those concepts. But, why not streamline the premedical and preclinical curricula, so students learn what they need only once?
The one-year preclinical model improves — but does not solve — inefficiency, cookie-cutter curriculum, and long training times. It also fails to address concerns that the fourth year of medical school is of questionable value.
The current system is unethical.
It’s clear that medical education is inefficient when numerous preclinical students skip lectures and watch recordings instead. It is well-known that many medical students do not even watch recordings from their own school: they detach from their institution’s curriculum and study solely using commercial USMLE Step 1 preparation materials.
One characterization of this trend states, “These commercial resources now define the de facto national curriculum of preclinical medical education.” Why, then, are students paying exorbitant tuition? It is absurd to force students to pay preclinical tuition when the use of USMLE Step 1 scores for residency applications incentivizes students to disengage from institutional curricula for the chance at a competitive score.
The time and youth of talented individuals are squandered as they are forced to relearn information they already know and learn material they will never use. Their money is wasted as they take out loans simply to learn from commercial curricula (which, of course, also cost money).
Such waste is unethical. It is wrong to mandate inefficiencies simply to “weed out” students (many students feel that the medical education system constructs hoops for them to jump through just for competition’s sake). Even worse, the mandatory wastefulness impedes socioeconomically disadvantaged individuals from entering medicine.
I do not suggest that the current system has no value: students can have the option to continue down the current path. They must, though, must have the ability to opt-out of wastefulness.
A new, technology-based solution
Technological innovations allow us to create modern, efficient, democratized modes of education. I propose a series of changes.
First, MD programs should be two years long and provide only clinical training. All basic science and preclinical competencies should be completed before medical school. Students are encouraged to use the saved training time to practice in underserved areas in return for tuition forgiveness.
Second, there must be personalized pathways into medical school.
Students can still attend a four-year bachelor’s program or enter from another career, community college, or accelerated premedical programs.
The key requirement is the successful completion of a standardized integrated premedical/preclinical curriculum. In addition to a holistic review of applicants’ backgrounds, application to medical school would be based on an examination analogous to USMLE Step 1 to demonstrate competency in preclinical skills. There is no need for the MCAT, which has redundant content (just another hoop to jump through) and serves as a socioeconomic gatekeeper.
Third, an integrated preclinical curriculum must be created. College premedical programs can continue providing instruction, but there should additionally be a standardized online curriculum that is accessible to all. Students should have the option to complete preclinical training through remote learning.
Remote learning for preclinical students is nothing new: as noted above, preclinical medical students already rely primarily on online resources to learn the material. Companies including Lambda School, Masterclass, Duolingo, Khan Academy, Coursera, and USMLE Step 1 preparation companies have shown it is possible to scale high-quality online coursework at a low cost.
Online platforms enable virtual lectures, student communities, peer-to-peer group-based learning, web-based simulation, etc. Virtual and augmented reality can be valuable for teaching anatomy, patient interaction, and more.
Across universities, there is already a trend of individual professors and courses building strong brands, such that students learn online from top experts across institutions. Similarly, why shouldn’t all preclinical students learn from the preeminent authorities and educators in each specific field?
Remote learning provides opportunities for individuals of all socioeconomic backgrounds to complete the premedical curriculum and apply to medical school, regardless if they can afford a four-year college.
Virtual premedical training can offer income share agreements to de-risk paying for preclinical education. Students would not pay for remote learning if they do not get into medical school — there is no need to take out loans just for a chance at admission.
My proposed framework could help diminish waste, save money, democratize medical education, alleviate the primary care shortage, mitigate burnout, and improve trainee wellness. The system can be piloted with a focus on students interested in primary care in underserved areas. It may feel uncomfortable to change a system that has been in place since the Flexner Report, but we must embrace innovation for the sake of future generations.
Figure 1. Models of medical education. Gap years are not shown. My proposed framework could reduce waste and mandatory training times, allowing focused students to start work earlier and alleviate primary shortages in underserved areas. The shortened training times also increase flexibility, helping students join tuition-forgiveness programs for practicing in underserved areas, undergo rigorous research training, participate in service projects, and more, all without sacrificing time relative to the current system. Source: Author’s analysis.
Jimmy J. Qian is a medical student.
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