Those who want to become a doctor in the United States stare at a very long road: 4 years of college, 4 years of medical school, 3-7 years of residency and, potentially, fellowship to finish it all off. (Some crazies additionally tack on another 1-5 years to do this in pursuing a joint degree, as well). But does it really require all this time to create a doctor well-equipped to fight disease in our current times?
None another than Ezekiel Emanuel and Victor Fuchs (one of the Founding Fathers of health economics) think that the answer is "no." In a recent piece in the Journal of the American Medical Association, they state that the current educational system for physicians is, in fact, wasteful. They point out that a physician today cannot credibly be the superhero, one-man-band of master clinician, penetrating researcher, community pillar, and public intellectual that she/he was expected to be up through the 1980s. The state that the complexity of medicine today requires a team based approach where doctors are relative specialists. Emanuel and Fuchs illustrate how physicians today are now more likely to take on the one (or two) of these archetypical roles that fit with their comparative strengths while letting other members of the larger team fulfill the other roles. In contrast to this new reality of medicine, our current system of medical education is wasteful because it still aims to produce one-man-band types.
So how can medical education be shortened? Emanuel and Fuchs suggest the following:
-Loosen requirements that undergraduate degrees be mandatory (there are plenty of six or seven year combined undergrad-MD programs that produce equally good doctors)
-Cut the pre-clinical years of medical school from 2 to 1.5 years (UPenn and Duke have shortened versions of the classroom years)
-Cut the clinical years from 24 to 15 months (Harvard is currently doing this, quite successfully I might add)
-Eliminate research requirements in residency and fellowship for those who do not want to do them (this, for example, would shave off 2 of the 7 years to become a general surgeon)
-Eliminate "leadership years" (for example, in internal medicine, the third year is to lead teams and has little value added in the education production function)
I am 100% behind this. Much of our current system persists because of historical considerations from nearly a century ago. In the same way that some of our antiquated mechanisms to finance health care (for example, employer sponsored health insurance) don't make much sense anymore, neither does making people spend a great deal of time in training where up to a third of it has little marginal benefit in turning people into good doctors.
If we are concerned with cost and efficiency in the health care system, we ought to paying as much attention to being efficient in how we train doctors as we are in figuring out how to pay them.
6 comments:
Just curious, how do you think adding more physician assistants and Nurse Practitioners will help/hurt in the changing responsibilities and training of doctors? I have been hearing a lot of pros about PA School in terms of years in school and satisfying salary/loans ratio but is this eventually a replacement for GPs?
Thanks for the comment. Your question is a good one and definitely relates to any reform in medical education.
As you probably know, PAs and NPs are increasingly involved in management decisions in ambulatory situations. And the research out there shows that they may be as good as MDs across a range of clinical outcomes (http://jama.ama-assn.org/content/283/1/59.short). With incentives to go into primary care still weak, a persistent shortange of GPs, and a need system wide to cut costs, one can only imagine more opportunities for PAs/NPs in this realm.
If this is the case, the onus on medical education might be to teach towards what the comparative advantage of an MD will be relative to an NP/PA. To some extent the existing system does this already. PAs, NPs likely will not have access to speciality and sub-speciality careers, and medical school and residency afford opportunities to learn about these areas. It may be that more emphasis is placed on spotting the rare cases and zebras, where an MD may be preferred to a PA/NP, in the future. Beyond this, it's hard to imagine exactly what the differences might be. I think we are still trying to find an equilibrium with respect to the allocation of MDs and PAs/NPs to clinical tasks.
An interesting question is what is a prospective health sector employee to do in deciding between choosing between PA/NP school versus med school. Shortening medical school would likely increase the potential supply of MDs (at least, the size of the pool of med school applicants). In the present setup, the decision comes down to how much one values the opportunities for further specialization, potentially higher income, and prestige. If these things are more valuable than the opportunity cost of schooling, an MD makes sense. Otherwise, it may not.
100 percent agree with your post. However, Regarding NPs/PAs, I have seen enough blunders from them in just 1 year of residency that I would be very reluctant to increase the scope of their practice.
Even to common outpatient conditions?
How would you define "common"? I think there is a very fine line between a seemingly "easy" clinical problem vs a hard one.
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