The NEW ENGLAND journal of medicine Perspective SEPTEMBER 19, 2013 BECOMING A PHYSICIAN A 3-Year MD.-Accelerating Careers, Diminishing Debt Steven B. Abramson, M.D., Dianna Jacob, R. P A, M. B.A., Melvin Rosenfeld, Ph. D, Lynn Buckvar-Keltz, M.D Victoria Harnik, Ph. D, Fritz Francois, M.D., Rafael Rivera, M.D., Mary Ann Hopkins, M.D., Marc Triola, M.D., and robert 1. grossman M. D t's been more than 100 years since Abrah Flexner proposed the current model for medical graph), as the prolongation of specialty training has delayed en education in North America: 2 years of basic science try into the workforce, reducing instruction followed by 2 years of clinical experience. 1 the productive years of clinicians and physician scientists. Com- Over the past several decades, This system results in rigid, time- pounding the effect of the in major changes have caused the based, non-learner-centered train- creased duration of training is medical community to reconsider ing. Recognizing this limitation, the growing number of entering current educational models. These the Carnegie Foundation recent- medical students who have taken changes include increasing educa- ly recommended that education "gap"years between college and tion costs, shifts in health care should"provide options for indi- medical school. National data needs, the demographics of the vidualizing the learning process dicate that the average age of applicant pool, and many scien- for students and residents, such as first-year medical students is 24 tific, pharmacologic, and tech- offering the possibility of fast At the New York University School nological advances resulting in tracking within and across levels. "1 of Medicine(NYUSOM), 55% of increased specialization of physi- In the past 30 years, the re- this year's entering medical stu- quired training period after med- dents have taken 1 or more gap Oversight of U.S. medical edu- ical school has increased sub- years cation is compartmentalized, with stantially, 2 but the time spent in Some analysts have suggested standards independently set for medical school has not been short- that the average duration of med undergraduate and graduate ac- ened. The average age of physi- ical training could be reduced by creditation by the Liaison Com- cians entering practice has there- approximately 30%- partly by mittee on Medical Education fore increased. Since 1975, the eliminating 1 year of medical (LCME)and the Accreditation percentage of physicians who are school -without compromising Council for Graduate Medical Ed- younger than 35 years of age has physicians' competence or the ucation (ACGME), respectively. decreased from 28% to 15%(see quality of care provided. Two N ENGL J MED 369: 12 NEJM.ORG SEPTEMBER 19, 2013 1085
Perspective The NEW ENGLAND JOURNAL of MEDICINE september 19, 2013 n engl j med 369;12 nejm.org september 19, 2013 1085 Over the past several decades, major changes have caused the medical community to reconsider current educational models. These changes include increasing education costs, shifts in health care needs, the demographics of the applicant pool, and many scientific, pharmacologic, and technological advances resulting in increased specialization of physicians. Oversight of U.S. medical education is compartmentalized, with standards independently set for undergraduate and graduate accreditation by the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME), respectively. This system results in rigid, timebased, non–learner-centered training. Recognizing this limitation, the Carnegie Foundation recently recommended that education should “provide options for individualizing the learning process for students and residents, such as offering the possibility of fast tracking within and across levels.”1 In the past 30 years, the required training period after medical school has increased substantially,2 but the time spent in medical school has not been shortened. The average age of physicians entering practice has therefore increased. Since 1975, the percentage of physicians who are younger than 35 years of age has decreased from 28% to 15% (see graph),3 as the prolongation of specialty training has delayed entry into the workforce, reducing the productive years of clinicians and physician scientists. Compounding the effect of the increased duration of training is the growing number of entering medical students who have taken “gap” years between college and medical school. National data indicate that the average age of first-year medical students is 24. At the New York University School of Medicine (NYUSOM), 55% of this year’s entering medical students have taken 1 or more gap years. Some analysts have suggested that the average duration of medical training could be reduced by approximately 30% — partly by eliminating 1 year of medical school — without compromising physicians’ competence or the quality of care provided.2 Two Becoming a Physician A 3-Year M.D. — Accelerating Careers, Diminishing Debt Steven B. Abramson, M.D., Dianna Jacob, R.P.A., M.B.A., Melvin Rosenfeld, Ph.D., Lynn Buckvar-Keltz, M.D., Victoria Harnik, Ph.D., Fritz Francois, M.D., Rafael Rivera, M.D., Mary Ann Hopkins, M.D., Marc Triola, M.D., and Robert I. Grossman, M.D. I t’s been more than 100 years since Abraham Flexner proposed the current model for medical education in North America: 2 years of basic science instruction followed by 2 years of clinical experience.1
PERSPECTIVE 3-YEAR M D.-- ACCELERATING CAREERS, DIMINISHING DEBT "age creep. "Although shortening UME training alone will not in crease the number of graduating physicians, it will allow graduates to enter practice sooner and there- 5 by increase the physician-years in practice on the national level, The 3-year pathway to the MD ill als so ena between UME and GME. cur- rently, U.S. medical schools with 1990 2011 3-year M.D. programs place grad- uates in residency programs at Percentage of Physicians in the United States Who Are Younger Than 35 Years of Age, their own institutions, engaging 1975-2011 students with mentors in the pro- gram during their first year of Canadian medical schools(Mc- the LCME's minimum require- medical school. Such connectivity Master University s Michael G. ment of 130 weeks of instruc- creates an opportunity to develop De Groote School of Medicine and tion. Unlike the Texas Tech and longitudinal competency-based the University of Calgary s Fac- Mercer programs, NYUSOM's assessment models that span the ulty of Medicine) award an M.D. model is not limited to the train- UME-GME continuum, tracking degree to all their students in ing of primary care physicians. learning and its effect on clinical 3 years. Several allopathic medi- Students in the accelerated pro- outcomes. As an increasing num- cal schools in the United States, gram have been offered condi- ber of medical schools adopt a including Texas Tech University tional acceptance, at the time of 3-year pathway, residency pro Health Sciences Center School of admission to medical school, into grams will probably begin ac- Medicine, Mercer University School a residency program at NYU Lan- cepting fast-tracked students from of Medicine, and most recently gone Medical Center. Interest in other programs, perhaps through NYUSOM, have introduced dedi- this new pathway was high: 50 of a consortium, extending the pos- cated pathways that offer select- the approximately 280 students sibility of tracking learner data ed students the option of obtain- who were initially offered admis- along the UME-GME continuum ing a medical degree in 3 years. sion to the medical school in across institutions In addition, a consortium of six 2013 submitted the required sup- Another benefit of a 3-year medical schools, comprising Texas plemental application for this pathway is its effect on reducing Tech, Mercer, Louisiana State Uni- pathway, indicating interest in 16 the student debt burden. The eco versity, Indiana University School different fields, including both nomic advantage to the student of Medicine, East Tennessee State medical and surgical specialties. is not only a 25% reduction in University, and the University of The NYU program also offers an debt, but also an additional year Kentucky, are in discussions to "opt-in"pathway, whereby stu- of earnings from entering the develop a 3-year M D. model. dents can defer the decision about workforce earlier. According The first cohort of 16 highly fast tracking and specialty choice the Association of American Med- competitive students was admit- until the beginning of year 3, ical Colleges(AAMC), in 2011, ted into the 3-year pathway at when they can make applications the mean medical school debt for NYUSOM this summer. These stu- to one of our(or in the future indebted graduates was $147, 188, dents had a mean grade-point other) graduate medical education with 64% of medical students average of 3.84 and a mean score (GME) programs carrying a debt of s of 36.5 on the Medical College One benefit of shortened train- more. 5 On the 2012 AAMC Medi- Admission Test(MCAT). Four had ing, whether at the premed, un- cal School Graduation Question already earned advanced degrees: dergraduate medical education naire, 50% of graduating medi 2 Ph. Ds and 2 master's degrees. (UME), or GME stage, is to help cal students reported that their Participating students will meet reverse the trend of physician level of educational debt influ N ENGL J MED 369: 12 NEJM.ORG SEPTEMBER 19, 2013
PERSPECTIVE 1086 n engl j med 369;12 nejm.org september 19, 2013 Canadian medical schools (McMaster University’s Michael G. DeGroote School of Medicine and the University of Calgary’s Faculty of Medicine) award an M.D. degree to all their students in 3 years. Several allopathic medical schools in the United States, including Texas Tech University Health Sciences Center School of Medicine, Mercer University School of Medicine, and most recently NYUSOM, have introduced dedicated pathways that offer selected students the option of obtaining a medical degree in 3 years. In addition, a consortium of six medical schools, comprising Texas Tech, Mercer, Louisiana State University, Indiana University School of Medicine, East Tennessee State University, and the University of Kentucky, are in discussions to develop a 3-year M.D. model.4 The first cohort of 16 highly competitive students was admitted into the 3-year pathway at NYUSOM this summer. These students had a mean grade-point average of 3.84 and a mean score of 36.5 on the Medical College Admission Test (MCAT). Four had already earned advanced degrees: 2 Ph.D.s and 2 master’s degrees. Participating students will meet the LCME’s minimum requirement of 130 weeks of instruction. Unlike the Texas Tech and Mercer programs, NYUSOM’s model is not limited to the training of primary care physicians. Students in the accelerated program have been offered conditional acceptance, at the time of admission to medical school, into a residency program at NYU Langone Medical Center. Interest in this new pathway was high: 50 of the approximately 280 students who were initially offered admission to the medical school in 2013 submitted the required supplemental application for this pathway, indicating interest in 16 different fields, including both medical and surgical specialties. The NYU program also offers an “opt-in” pathway, whereby students can defer the decision about fast tracking and specialty choice until the beginning of year 3, when they can make applications to one of our (or in the future other) graduate medical education (GME) programs. One benefit of shortened training, whether at the premed, undergraduate medical education (UME), or GME stage, is to help reverse the trend of physician “age creep.” Although shortening UME training alone will not increase the number of graduating physicians, it will allow graduates to enter practice sooner and thereby increase the physician-years in practice on the national level, helping to address the shortage. The 3-year pathway to the M.D. degree will also enable linkage between UME and GME. Currently, U.S. medical schools with 3-year M.D. programs place graduates in residency programs at their own institutions, engaging students with mentors in the program during their first year of medical school. Such connectivity creates an opportunity to develop longitudinal competency-based assessment models that span the UME–GME continuum, tracking learning and its effect on clinical outcomes. As an increasing number of medical schools adopt a 3-year pathway, residency programs will probably begin accepting fast-tracked students from other programs, perhaps through a consortium, extending the possibility of tracking learner data along the UME–GME continuum across institutions. Another benefit of a 3-year pathway is its effect on reducing the student debt burden. The economic advantage to the student is not only a 25% reduction in debt, but also an additional year of earnings from entering the workforce earlier. According to the Association of American Medical Colleges (AAMC), in 2011, the mean medical school debt for indebted graduates was $147,188, with 64% of medical students carrying a debt of $100,000 or more.5 On the 2012 AAMC Medical School Graduation Questionnaire, 50% of graduating medical students reported that their level of educational debt influA 3-Year M.D. — Accelerating Careers, Diminishing Debt Percentage of Physicians in the U.S. <35 Yr of Age 30 5 10 0 15 20 25 1975 1980 1990 2000 2011 Percentage of Physicians in the United States Who Are Younger Than 35 Years of Age, 1975–2011
PERSPECTIVE ACCELERATING CAREERS, DIMINISHING DEBT enced their choice of specialty. assessment-ideally, a standard- spent in training is an important Student debt burdens also adverse- ized national assessment model. factor in medical instruction, and ly affect the economic and racial In the years ahead, developing a the process of becoming a physi or ethnic diversity of the medical uniform set of milestones and cian requires an extended period school population, thereby reduc- competencies whereby assessment (premed, UME, and GME)of both ing the diversity of the physician cuts across each level of medical learning and practical experiences workforce school, residency, and fellowship, We must ensure the value and ef- Concerns about a 3-year path- thus linking UME and GME as a ficiency of our educational efforts way include the sense that though continuum of learning, will be a appreciating the various ways in the fourth year is often under- major task for medical educators. which trainees at all levels will be utilized, it can be a valuable mat- The need for medical educa- able to master the requisites nec- uration period for many stu- tion reform in the post-Flexnerian essary for entering the medical dents, providing opportunities for era is widely recognized. We need profession and advancing within it. research or additional clinical to address the ways in which Disclosure forms provided by the authors posure. Related concerns include physicians acquire and manage are available with the full text of this article at NEJM.org the potential loss of exploration information, utilize technology, An audio interview with Dr.Richard and enjoyment in the medical ed- and serve the country's needs Schwartzstein about 3-year M D programs ucation process. Certainly, careful while delivering culturally com- can be heard at NEJM. org mentoring and monitoring, be- petent care that reduces health ginning at the time of matricula- disparities. The past three dec- From NYU Langone Medical Center, New to opt in or opt out, are essential ening of the training process, 1. Irby DM, Cooke M,O'Brien BC.Calls for for the success of any accelerated driven by isolated decision mak- reform of medical education by the Carnegie raining program ing at the individual program- ing: 1910 and 2010.Acad Med 2010:85:220.7. Shortening UME training for matic level. We are at a point of 2. Emanuel E), Fuchs VR Shortening med selected students should be viewed inflection where a coordinated cal training by 30%6 JAMA 2012 307: 1143 as just one approach to address- approach spanning the silos of 3nd mastr utio n i n the us. hiaacteseris ing the need for change in the UME, GME, accrediting organi- can Medical Association,2013 post-Flexnerian era. Shortening zations, and health care delivery 4 Krupka C Med school on the fast track bringsitsownchallengesparsystemsiscriticalwEneedtoMay7,20i2(http://www.ama-assn.org/ ticularly the need to assess com- train physicians who are com- amednews/2012 /05/07 /prl20507 htm) petency in the fast-tracked UME mitted to lifelong learning and 5. Greysen SR, Chen C, Mullan F. A history model. Indeed, if medicine shifts who are passionate and highly cations for the future of medical education away from traditional time-based trained care providers, as well as Acad Med 2011: 86:840-5 evaluation,such evaluation must scientists and leaders of a new Dol: 10. 1056/NEJMp1304681 be replaced by competency-based health care delivery model. Time Copyright e 2013 Massachusetts Medical Society. BECOMING A PHYSICIAN The 3-Year Medical School -Change or Shortchange? Stanley Goldfarb, M.D., and Gail Morrison, M D hortening medical school to medical education, however, sug. learning and small programs that 3 years, some observers argue, gest that doing so is unwise- create unusual opportunities for would increase the supply of phy- a conclusion supported by assess- such students, but we believe sicians- perhaps particularly ments of the readiness of todays that for the typical student seek primary care physicians - and medical school graduates to as- ing an M D degree, the duration reduce the cost of medical train- sume increased clinical responsi- of medical school should not be ing, without compromising clini- bility as they enter residency pro- shortened cal care. 1 Data from many years grams. 2 There may be exceptional There are many examples of of experiments in shortening students capable of accelerated past attempts to shorten training ENGLJMED 369: 12 NEJM. ORG SEPTEMBER 19, 2013
n engl j med 369;12 nejm.org september 19, 2013 PERSPECTIVE 1087 enced their choice of specialty. Student debt burdens also adversely affect the economic and racial or ethnic diversity of the medical school population, thereby reducing the diversity of the physician workforce.5 Concerns about a 3-year pathway include the sense that though the fourth year is often underutilized, it can be a valuable maturation period for many students, providing opportunities for research or additional clinical exposure. Related concerns include the potential loss of exploration and enjoyment in the medical education process. Certainly, careful mentoring and monitoring, beginning at the time of matriculation, as well as the opportunity to opt in or opt out, are essential for the success of any accelerated training program. Shortening UME training for selected students should be viewed as just one approach to addressing the need for change in the post-Flexnerian era. Shortening brings its own challenges, particularly the need to assess competency in the fast-tracked UME model. Indeed, if medicine shifts away from traditional time-based evaluation, such evaluation must be replaced by competency-based assessment — ideally, a standardized national assessment model. In the years ahead, developing a uniform set of milestones and competencies whereby assessment cuts across each level of medical school, residency, and fellowship, thus linking UME and GME as a continuum of learning, will be a major task for medical educators. The need for medical education reform in the post-Flexnerian era is widely recognized. We need to address the ways in which physicians acquire and manage information, utilize technology, and serve the country’s needs, while delivering culturally competent care that reduces health disparities. The past three decades have seen a gradual lengthening of the training process, driven by isolated decision making at the individual programmatic level. We are at a point of inflection where a coordinated approach spanning the silos of UME, GME, accrediting organizations, and health care delivery systems is critical. We need to train physicians who are committed to lifelong learning and who are passionate and highly trained care providers, as well as scientists and leaders of a new health care delivery model. Time spent in training is an important factor in medical instruction, and the process of becoming a physician requires an extended period (premed, UME, and GME) of both learning and practical experiences. We must ensure the value and efficiency of our educational efforts, appreciating the various ways in which trainees at all levels will be able to master the requisites necessary for entering the medical profession and advancing within it. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. An audio interview with Dr. Richard Schwartzstein about 3-year M.D. programs can be heard at NEJM.org. From NYU Langone Medical Center, New York. 1. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med 2010;85:220-7. 2. Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA 2012;307:1143-4. 3. Smart DR, ed. Physician characteristics and distribution in the US. Chicago: American Medical Association, 2013. 4. Krupka C. Med school on the fast track: a 3-year degree. American Medical News. May 7, 2012 (http://www.ama-assn.org/ amednews/2012/05/07/prl20507.htm). 5. Greysen SR, Chen C, Mullan F. A history of medical student debt: observations and implications for the future of medical education. Acad Med 2011;86:840-5. DOI: 10.1056/NEJMp1304681 Copyright © 2013 Massachusetts Medical Society. A 3-Year M.D. — Accelerating Careers, Diminishing Debt Becoming a Physician The 3-Year Medical School — Change or Shortchange? Stanley Goldfarb, M.D., and Gail Morrison, M.D. Shortening medical school to 3 years, some observers argue, would increase the supply of physicians — perhaps particularly primary care physicians — and reduce the cost of medical training, without compromising clinical care.1 Data from many years of experiments in shortening medical education, however, suggest that doing so is unwise — a conclusion supported by assessments of the readiness of today’s medical school graduates to assume increased clinical responsibility as they enter residency programs.2 There may be exceptional students capable of accelerated learning and small programs that create unusual opportunities for such students, but we believe that for the typical student seeking an M.D. degree, the duration of medical school should not be shortened. There are many examples of past attempts to shorten training
