Accelerated Medical Education: Past, Present and Future

Medical education has gone through a number of reforms and innovations over the past century. Included in that history are the multiple efforts to “accelerate” medical education. The reasons behind these acceleration efforts are generally, but not always, aimed at producing physicians faster, more economically, or both.

The national discussion on the acceleration of medical education is re-emerging now due to the escalating costs of medical education, the level of educational debt of graduating medical students, and the predicted worsening of the physician workforce shortage, especially in light of the recent passage of the Affordable Care Act (ACA)^1,2 The Association of American Medical Colleges (AAMC) Center for Workforce Studies estimates the current national shortage of physicians at 60,000 and projects that number to increase to 90,000 by 2020.³ Medical school tuition and fees average $30,000–$50,000-depending on public or private medical school status-with 86% of students graduating with median debt that averages $162,000. Cost of attendance (including living expenses) in medical school continues to rise with average annual costs of $56,000–$75,000, again depending on public or private status of the medical school (AAMC data available online at AAMC.org).

The realities of the shortages of physicians and the cost of education, largely born by the medical students, but also subsidized by clinical revenues, is leading to a call to re-examine the length of education and training of physicians.^1,2 The prevailing model of medical education in the United States leading to the MD degree is eight years: four years toward a baccalaureate degree, followed by four years of medical school. This model is based on the reformations in medical education from a century ago and articulated in the Flexner Report⁴ commissioned by the Carnegie Foundation and published in 1910.

To address the lack of standards of medical education and poor quality of medical training in existence in the late 1800s, Flexner called for admissions requirements, university-based medical schools, and a four-year medical school curriculum with two years of basic sciences followed by two years of clinical instruction in a teaching hospital. Even before the Flexner Report, the AAMC, the American Medical Association (AMA) and state licensing boards were recommending and setting standards that included pre-matriculation college education and a four-year medical school curricula with two years each of basic and clinical sciences.^5,6 These reformations resulted in the closing of approximately half of the existing medical schools and standardization of the four-year medical school curriculum across the remaining schools.

In an effort to continue innovation in medical education, as early as 1926⁷ the AAMC noted that medical schools should be “encouraged” to undertake “educational experiments” with the goal of improving medical education. They also made provisions for US medical schools to follow the six-year model of Canadian schools of “combined collegiate and medical curriculum,” provided that the curriculum include the same content.

“Accelerated” programs were initiated during World War II in order to produce physicians quicker for the war effort.⁸ All but six of the medical schools at that time adopted accelerated programs, which were approved by the AAMC and the Federation of State Medical Boards (FSMB). These programs were shortened from four years to three by eliminating summer breaks, but were forbidden from “lowering standards” and could not “condense, curtail or abbreviate any course of instruction.”⁸ After the war, the medical schools all returned to the pre-war formats. Interestingly, one of the perceived drawbacks of the accelerated programs was the financial burden on the medical students who routinely worked during summer breaks in order to afford to attend medical school. Another drawback was the financial stress on the resources of the medical schools due to faculty being taken away from the research and clinical missions to teach on a more intensive schedule.

The modern era of “accelerated” medical education programs began in the 1960s and 1970s⁹ and took two forms: combined baccalaureate-MD programs and three-year medical school programs. The first four accelerated, baccalaureate-MD programs opened in the early 1960s as tracks within established medical schools (Northwestern University, Boston University, Jefferson Medical College-Penn State University, and Albany Medical College).

The Three-Year Medical School

The initial accelerated, combined degree programs of the early 1960s were not primarily driven by the mission to address physician workforce shortages. Rather, they were intended to offer an accelerated track to bright high school students, reduce educational expense to the students, and enhance the humanities and/or technical education. By the late 1960s and early 1970s, though, national concern over projected physician shortages, especially in primary care was beginning to grow. The influential “Bane Report” predicted a national shortage of 40,000 physicians by 1975.¹⁰ The Carnegie Commission published a report in 1970¹¹ that recommended the acceleration of medical education to reduce costs and produce physicians quicker by reducing medical school from four years to three. They noted one central weaknesses of the Flexner model: duplication of the expense of scientific efforts between the parent university and the medical school and praised the “integrated science models” of the combined degree programs.

Although not the initial mission, the combined degree programs in the late 1960s and early 1970s adopted the goal of producing physicians faster for the perceived needs of the communities they served. The predicted physician shortage led to federal policy to fund the opening of new medical schools, both traditional and combined degree programs. By 1971, capitated federal funding was appropriated for existing schools to receive $2000 per student graduating from a three-year accelerated program. This funding drove the development of the three-year medical school programs in the early 1970s,¹² such that by 1973, over a quarter of the existing medical schools had three-year medical education programs.

While student performance and “physician readiness” have been cited as a criticism for accelerated programs,^1,13 student performance in these three-year programs remained good. Rather it was the programs’ poor acceptance by faculty that largely shuttered them by the late 1970s. The subsequent publication of the Graduate Medical Education National Advisory Committee (GMENAC) report in 1981,¹⁴ predicting an oversupply of physicians, ended the push for accelerated programs for the purpose of producing physicians faster. Between 1960 and 1982, 37 new medical schools opened (list available through the Liaison Committee on Medical Education at lcme.org) but after the GMENAC report, it would be 20 years before a new medical school would open.

The Combined Baccalaureate-MD Model

Because the initial mission of the combined, baccalaureate-MD programs was not primarily targeted toward physician shortages, these programs persisted after the GMENAC report and continue to grow in number and variety. By 1992, there were 28 medical schools (of 125 total MD-granting medical schools) with 30 combined degree programs.⁹

The University of Missouri-Kansas City (UMKC) School of Medicine is concluding the year-long celebration of the 40th anniversary of opening in 1971.

Currently, there are 57 medical schools (of 138 MD-granting medical schools) offering 81 baccalaureate-MD programs.¹⁵ Most of these programs are small tracks within the larger programs. Only three programs admit the majority of their student body into the baccalaureate-MD program: University of Missouri-Kansas City (UMKC), Northeastern Ohio Medical University College, and the Sophie Davis School of Biomedical Education of the City University of New York.

Although many of the programs started or adopted accelerated schedules during the perceived physician shortage of the 1960s and 1970s, the trend has been for most programs to lengthen over time and the majority of programs are currently eight years. Only nine programs are now seven years in length and five programs are six years in length¹⁵. All of the combined degree programs that are less than eight years include four years of medical school instruction. The shortening of the programs are through shortening the baccalaureate time or through dual credit for toward both degrees, but not through shortening the medical curriculum.

The baccalaureate-MD programs across the United States serve a number of missions, both historic and new: recruitment of bright high school students to retain them in medicine, integration of liberal arts and medical school curriculum, focus on special tracks (rural health, primary care, underserved populations, biotechnology, humanities, etc.), recruitment and mentoring of diverse students, reduction of competition and stress of applying for medical school, reduction in cost of medical education,^9,15 and increased involvement of faculty. Many schools have published their results regarding effectiveness of meeting their missions,^16,17 as well as student outcomes.

The academic performance of students in baccalaureate-MD programs are comparable, and in some cases better than students in traditional curricula.^9,13,17–20 There is some evidence that students recruited into these programs from high school experience less stress, perceive a less competitive environment, and have higher concordance between expectations and experiences.^18,21–24 Furthermore, the graduates of baccalaureate-MD programs perform well in residency programs compared to peers from traditional undergraduate medical schools.^17,18,24 The perception of the students themselves is positive.^18,22 The attrition in baccalaureate-MD programs is higher than traditional programs and occurs primarily in the first two years, after which it approximates traditional medical schools.²⁴ However, the attrition in baccalaureate-MD programs is less than half of the attrition of traditional premedical programs, and thus may be a means to keep students in medicine that other wise might choose other careers while in college.

Our experience at UMKC concurs with the literature, in terms of high performance of graduates clinically and favorable student perceptions.^13,17,24 In Missouri, Washington University and Saint Louis University, in addition to the University of Missouri-Kansas City have baccalaureate-MD programs. The program at UMKC admits the majority of students into the baccalaureate-MD program and is six years in length. The other two programs are tracks within the larger programs and are eight years in length. The University of Missouri-Kansas City program shortens the length to six years through integration of the liberal arts and medical school courses to avoid duplication and through elimination of summer breaks. Students attend school 11 months per year, with one month of vacation annually.

The Future of Medical Education

There are now 50 years of national experience with baccalaureate-MD programs, as well as 70 years of experience with a variety of accelerated programs, including some of the baccalaureate-MD programs. The 40-year experience at UMKC provides substantially to the literature in this regard. Our approach is “an applied education theory of relevance, repetition, responsibility, and role models.”¹³ This approach is efficient in time, while rich in content and experience and with good educational outcomes.¹⁷

The themes of physician shortages, cost of medical education to students, expense of medical education to institutions, redundancies in the curriculum between premedical college and medical school, and the need to innovate in medical education are recurring over time and have recently amplified^1,2 with the passage of the Affordable Care Act (ACA). While we are constantly reminded of the medical education debt burden, multiple analyses on the cost of medical education repeatedly conclude that shortening the length of medical education is the most effective means to reduce cost to both students and institutions.^2,25 A recent analysis indicates that reducing medical school by one year provides the greatest financial benefit for graduating physicians, between $160,000–$230,000.²⁵

As we move beyond 100+ years of medical education post-Flexner, it is perhaps time to revisit how we train physicians over the next 100 years as medicine and technology rapidly evolves. In any event, changes in medical education must 1) maintain the learning environment and educational quality for students, 2) fit within the faculty and institutional resources of the academic medical centers and universities, and 3) provide high quality physicians of the numbers and types needed by the public.

A recent JAMA commentary¹ set a goal of reducing the entire continuum of formal medical education by 30%. While there are many ways to achieve this, many lessons can be learned from studying the innovations in undergraduate medical education among the accelerated programs and the current baccalaureate-MD programs. These programs have a rich collection of data on the quality of their programs, as well as experience in shortening the medical education program while preserving quality and reducing cost. Changes in medical education should include the study of the programs currently in existence, as well as prospective research and study of the outcomes in terms of quality, cost, and student perspective.

Biography

Betty M. Drees, MD, MSMA member since 2000, (left) is Dean and Professor of Medicine at the University of Missouri - Kansas City School of Medicine. Kenan Omurtag, MD, (above) is a Fellow in the Division of Reproductive Endocrinology and Infertility in the Department of Obstetrics and Gynecology at the Washington University School of Medicine in St. Louis.

Contact: DreesB@umkc.edu