Thoughts on Medical Education

One of the things we all have in common is our exposure to the medical education system. Now, we’ve had different experiences. Some of us are MDs, some DOs. Some have been educated in foreign schools, either in their home countries, or in international venues. And we all have opinions about our own education, and how we should be educating our successors. In my case, I’ve spent all of my career in teaching hospitals, with both residents and students. I’ve had a lot to do with medical education. Being part of the system has been something of a mixed experience.

It has been more than 100 years since the Flexner report in 1910 condemned the general quality of medical education. The report held up as an ideal the Johns Hopkins model of university-based post-graduate physician education. Since then, this model has become almost universal in the United States and Canada, with some variations between MD and DO schools. Medicine has become totally integrated into higher education, with all that implies for quality of medical education. All students mix classroom education with “hands-on” work in hospitals. While the level of responsibility allowed to students has decreased steadily over the past 30–40 years, students still see patients, and participate in their care.

But the model is beginning to show its age. Most obviously, it’s failed to meet society’s demand for physicians. Granted, US schools have been expanding recently, but we’re still not keeping up. We have widespread shortages in nearly all specialties.

One side effect of the shortage has been the development of some 31 “offshore” schools in the Caribbean.¹ These schools are closer to the 19th-century proprietary schools than they are to the Hopkins model. Academic classwork is in the school, instruction is in English, and clinical training usually takes place in US hospitals with considerably less direct supervision than is common in MD and DO schools in the US. Whatever one may think about the quality of these schools, they are fully subscribed. Collectively, they turn out several thousand physicians per year.

The medical education system doesn’t serve students particularly well. The cost is astronomical. The average student graduates with $200,000 of educational debt. Imagine the burden on students who marry one another. And of course, we underpay residents so badly that the debt simply accumulates. To get through the process, a student must undergo at least three high-stakes selection processes. Undergraduate college, medical school, and then residency. And maybe one or two more for fellowships. Plus, an ever-increasing number of national examinations. Small wonder that the smart kids are going into engineering or computer science.

From the student’s standpoint, the system wastes a lot of time. Four to six years of undergraduate, four years of medical school and then three to ten years of residency and/ fellowship training. The biggest change since 1910 has, of course, been resident education. Making medicine a four-year post-graduate school was a great idea in 1910. Today, we’re piling on the years. The age of finishing resident education is up to the mid- or late-thirties. The sheer amount of knowledge required of today’s physician makes it difficult to cut much time out of medical school. University of Missouri - Kansas City manages to cut college plus medical school down to six years, so it can be done. But only one other school in the country is doing that. While other types of accelerated programs are enjoying a small surge of popularity, past surges have died out.

To add insult to injury, we’re busily adding medical school capacity to a system without adding residency positions. Right now, there aren’t enough positions for all graduates. Currently, 6% of US medical school graduates go unmatched, as do 50% of foreign graduates. Including American graduates of Caribbean schools. Now, only about 600 of the 5,000 acute care hospitals have residency programs. And only about 300 have multiple programs. There are many hospitals that could support residency training, but have chosen not to. Why? There are a lot of barriers. Many physicians, perhaps most, are unwilling to commit to the time and effort required to train residents. Patients often have mixed feelings about being cared for by residents. Most new medical schools are being established around hospitals which already have residency programs, so a new school does not mean new residency slots. Hospitals find it expensive, even with Federal subsidies for residency training. The Federal subsidy is capped. Although there is some room for new programs, it is very hard to expand existing programs. Lastly, accreditation for new programs is fairly difficult, as it should be.

Let’s see. Medical students are poorly served. Residents are overworked and underpaid. There aren’t enough residency slots. Does the system work well for anyone? Well, medical school faculty do well enough. I’ve had a great career as a faculty physician. They’re often overworked, but that’s true for all doctors. They tend to be underpaid relative to other physicians in the same specialty, so that’s sort of a minus. Job security is pretty good, unless you move up to a chair. Deans do very well, often making nearly as much as hospital executives. But their turnover makes mayflies look long-lived, so there’s a lot of insecurity.

Teaching hospitals are clear winners. We have built some of the world’s best hospitals and health systems around our major teaching hospitals. Locally, imagine Kansas City without Kansas University Medical Center or Truman Medical Center. Whatever we do to fix the system, we should preserve these institutions. Indeed, while the teaching hospital model is too expensive for all hospitals, we would be well-advised to incorporate that model into more of our non-teaching hospitals.

We do not, let me say, need a 21st century Flexner report. Our medical education system continues to produce bright and well-trained young physicians. Residency programs do a very good job of training both generalists and specialists. We’re doing something right. No, we’re doing a great deal right. But we need to improve How?

We should reduce barriers to medical education. Early commitment to medical school would help. Shortening both undergraduate and medical school would be positive. Further, it is vital to increase the number of residency positions available. Right now, we have 28,000 positions and 42,000 applicants, or 1½ applicants for each position.² There’s a long way to go. Creating more residency slots is absolutely vital. The increased number of medical school graduates isn’t going to do any good if they cannot get trained.

As noted above, the teaching hospital model is extremely strong. But it is also expensive and difficult. Many hospitals simply cannot afford to have residents, and many physicians cannot afford to incorporate teaching activities into their practices. So as we are making up our wish list, we need to address how we can incorporate teaching into more hospitals and more practices.

We should remove harassments. Right now, we require four separate tests of students, three of which are before graduation. The silliest of these is Step 2CS, which requires students to pay $1,000, travel to one of six centers, and talk with “simulated” patients to test whether they can take a history and physical.³ Really? Our schools are so bad that we need to test the medical equivalent of reading and writing? The pass rate is 96% for US graduates, so it’s not as if the test serves any real purpose. Of course, somebody benefits. The USMLE collects in the neighborhood of $20 million a year from students taking the exam.

We should do something about debt. The national need for physicians is a serious matter. Perhaps we should underwrite medical education, to a much greater degree than at present. Universities tend to view medical schools as cash cows, and medical students as captives. Of course, the problem isn’t just medical schools. Cost inflation in higher education is about twice as high as health care cost inflation, which itself is twice as high as everything else. Somehow, we need to get educational costs under control. If education is a national priority, as all politicians say it is, then why do we keep making it more expensive?

What can we do to make residency training more bearable? We’ve cut down somewhat on the workload, but it’s still very high. Pay is pretty much capped because Medicare pays for most residency training. And of course, no hospital will pay residents more than they get from the Feds. It’s cheap labor, after all. Supply and demand doesn’t work here. It’s a controlled market. But residents still should be paid better. Paying subsistence wages to a 35-year-old professional is not going to motivate young people to follow us into medicine.

The system isn’t broke. But it’s creaking. It’s time to fix it before it DOES break.

Biography

Charles W. Van Way, III, MD FACS, FCCP, FCCM, MSMA member since 1989, Missouri/AMA Delegate, and Missouri Medicine Contributing Editor, is Director of the UMKC Shock Trauma Research Center.

Contact: cvanway@kc.rr.com