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
PERSPECTIVE 3-YEAR MEDICAL SCHOOL- CHANGE OR SHORTCHANGE by combining baccalaureate and points have emerged. Both stu- may soon choose a career. Most medical education (B.A. -M D. dents and faculty felt pressured students spend several months into a 6- or 7-year experience. by the compression of material. pursuing electives at institutions Western Reserve University made As many as 25% of students ne- that rank high among their resi- the first attempt in the 1950s. By gated the supposed benefits of dency-site choices. They also 2011, some fraction of the enter- an accelerated program by volun- spend 2 to 3 months interview- ing medical school class at 67 tarily extending their education ing at the hospitals where they U.S. schools were students pur- by 1 or 2 years. Even as these would consider pursuing post- suing combined BA -M.D. de- students were often stigmatized graduate training. If the fourth grees; 39% of community-based as weak or deficient for failing to year were eliminated, these activi- medical schools and 33% of re- complete the program in 3 years, ties would need to occur during search-intensive schools had such students who were able to com- the third year, further compro programs. But among schools plete the program in that time mising clinical education, or offering a BA-M D. program, felt exhausted, "having studied would have to be abandoned the proportion that compressed in an uninterrupted slog through Though some observers argue their curriculum into 6 years 34 of the programs 36 months. that these efforts to sort through opped from 23% in 1990 to Perhaps most important, there career options and residency pro 7% in 2011, and the proportion was substantial faculty dissatis- grams lack educational value, requiring 7 years fell from 32% faction with the adequacy of the they are necessary steps for stu- to 13%. Thus, only 20% of the curriculum. The expansion of dents who are asked to fund medical schools that once hoped medical knowledge since that their medical education and are to abbreviate the duration of time, combined with a recent therefore entitled to shape the B.A.-M.D. education now offer trend toward reducing the pre- location and nature of their post programs shorter than 8 years. 3 clinical curriculum to 1.5 years, graduate training Moreover, even in these programs, puts even more pressure on the In addition, access to global most of the time savings result faculty to provide a comprehen- health experiences; instruction in from reducing the B A. portion sive education and on students to medical ethics, principles of pa of the curriculum while main- gain required knowledge tient safety and health polie taining a 4-year medical school Other aspects of the failed ex- and advanced clinical experienc curriculum. Indeed, the number periment of 40 years ago reso- es are extremely valuable compo- of schools reducing the duration nate in the current proposals. nents of the current fourth year of the medical school component The hope that students would Moreover, there is a recent trend has declined dramatically. In 1974, opt for primary care careers was toward students' seeking ever a total of 33 schools allowed stu- not consistently borne out. Stu- longer terms for medical school, dents to obtain an M.D. degree dents enrolling in some acceler- with the opportunity to gain ad- after 3 years in their curriculums ated BA -M.D. programs in ditional credentials, including medical school component, but community-based medical schools masters degrees, certificates of such options virtually disappeared tended to enter careers in family added competence, and prolonged from the scene thereafter, only medicine in higher numbers than research-training experiences. All to reappear in 2013 in two nas- did those from standard M.D. pro- these activities speak to students' cent programs aiming to pro- grams, but even those numbers sense of an expanding leadership duce primary care physicians. were nowhere near the hoped- role for physicians on future The reasons articulated in 1970 for 60 to 75% and overall. these health care teams. for embarking on a 3-year curric- programs did not consistently In our view, the third year of ulum were the same as those boost the number of students medical school curricula requires cited today: to reduce the cost of choosing primary care careers. reform, since students currently education and to increase the At one time, the fourth year of have inadequate opportunity for number of primary care physi- medical school was spent exclu- the direct patient contact that cians in a country facing anan- sively in outpatient care settings, they need to become independent ticipated physician shortage. 5 The but its emphasis has largely shift- caregivers. Work-hour regulations causes of the failure of those ed to inpatient electives, through apply to students as well as resi- 3-year progra aims are n ot well which students seek broad expe- dents, and the current height documented, but some common rience in fields in which they ened focus on efficiency and N ENGL J MED 369: 12 NEJM.ORG SEPTEMBER 19, 2013
PERSPECTIVE 1088 n engl j med 369;12 nejm.org september 19, 2013 by combining baccalaureate and medical education (B.A.–M.D.) into a 6- or 7-year experience. Western Reserve University made the first attempt in the 1950s. By 2011, some fraction of the entering medical school class at 67 U.S. schools were students pursuing combined B.A.–M.D. degrees; 39% of community-based medical schools and 33% of research-intensive schools had such programs. But among schools offering a B.A.–M.D. program, the proportion that compressed their curriculum into 6 years dropped from 23% in 1990 to 7% in 2011, and the proportion requiring 7 years fell from 32% to 13%. Thus, only 20% of the medical schools that once hoped to abbreviate the duration of B.A.–M.D. education now offer programs shorter than 8 years.3 Moreover, even in these programs, most of the time savings result from reducing the B.A. portion of the curriculum while maintaining a 4-year medical school curriculum. Indeed, the number of schools reducing the duration of the medical school component has declined dramatically. In 1974, a total of 33 schools allowed students to obtain an M.D. degree after 3 years in their curriculum’s medical school component,4 but such options virtually disappeared from the scene thereafter, only to reappear in 2013 in two nascent programs aiming to produce primary care physicians. The reasons articulated in 1970 for embarking on a 3-year curriculum were the same as those cited today: to reduce the cost of education and to increase the number of primary care physicians in a country facing an anticipated physician shortage.5 The causes of the failure of those 3-year programs are not well documented, but some common points have emerged. Both students and faculty felt pressured by the compression of material. As many as 25% of students negated the supposed benefits of an accelerated program by voluntarily extending their education by 1 or 2 years. Even as these students were often stigmatized as weak or deficient for failing to complete the program in 3 years, students who were able to complete the program in that time felt “exhausted,” having studied in an uninterrupted slog through 34 of the program’s 36 months.5 Perhaps most important, there was substantial faculty dissatisfaction with the adequacy of the curriculum. The expansion of medical knowledge since that time, combined with a recent trend toward reducing the preclinical curriculum to 1.5 years, puts even more pressure on the faculty to provide a comprehensive education and on students to gain required knowledge. Other aspects of the failed experiment of 40 years ago resonate in the current proposals. The hope that students would opt for primary care careers was not consistently borne out. Students enrolling in some accelerated B.A.–M.D. programs in community-based medical schools tended to enter careers in family medicine in higher numbers than did those from standard M.D. programs, but even those numbers were nowhere near the hopedfor 60 to 75%; and overall, these programs did not consistently boost the number of students choosing primary care careers. At one time, the fourth year of medical school was spent exclusively in outpatient care settings, but its emphasis has largely shifted to inpatient electives,5 through which students seek broad experience in fields in which they may soon choose a career. Most students spend several months pursuing electives at institutions that rank high among their residency-site choices. They also spend 2 to 3 months interviewing at the hospitals where they would consider pursuing postgraduate training. If the fourth year were eliminated, these activities would need to occur during the third year, further compromising clinical education, or would have to be abandoned. Though some observers argue that these efforts to sort through career options and residency programs lack educational value, they are necessary steps for students who are asked to fund their medical education and are therefore entitled to shape the location and nature of their postgraduate training. In addition, access to global health experiences; instruction in medical ethics, principles of patient safety, and health policy; and advanced clinical experiences are extremely valuable components of the current fourth year. Moreover, there is a recent trend toward students’ seeking even longer terms for medical school, with the opportunity to gain additional credentials, including master’s degrees, certificates of added competence, and prolonged research-training experiences. All these activities speak to students’ sense of an expanding leadership role for physicians on future health care teams. In our view, the third year of medical school curricula requires reform, since students currently have inadequate opportunity for the direct patient contact that they need to become independent caregivers. Work-hour regulations apply to students as well as residents, and the current heightened focus on efficiency and 3-Year Medical School — Change or Shortchange?
PERSPECTIVE 3-YEAR MEDICAL SCHOOL- CHANGE OR SHORTCHANGE? safety can impede students'abil- pand their knowledge in both need even more advanced educa- ity to gain required procedural clinical and non-clinical do- tion in health policy, public skills and to develop close rela- mains. Truncating the medical health needs, clinical research tionships with patients. We school experience would make it and medical ethics -in order to strongly believe that educators far more difficult to aco lead such teams, But we believe should ensure that each clinical that goal. that, at the very least, physicians rotation is actually a course in a To better prepare students for will succeed as team leaders only ply a 1- or 2-month period of clinical involvement or observation both outpatient and inpatient set- creditation Council for Graduate of clinical care. Extensive didac- tings are needed and that inno- Medical Education. That requires tics and the use of new tools for vative advising and mentoring enhancement, not shortening, of evaluating students'competence programs should be created to medical schooL. in each discipline should be re- enhance the transition to resi- Disclosure for l clerkship. The fourth year, plexity of medicine, it seems at nejMo? rms provided by the authors quired components of each clini- dency. Given the growing com- the full text of this article then, should be a time to hone counterproductive to compress An audio interview with Dr. Richard ut 3-year M.D. programs these new clinical skills and nar- the curriculum into 3 years, re- can be heard at NEJM.org. ducing both preclinical and Unfortunately, the current clinical experiences. The limited From the Perelman School of Medicine, fourth year fails to prepare many opportunity for students to par- University of Pennsylvania, Philadelphia students for more advanced re- ticipate meaningfully in patient sponsibilities. In a 2009 survey, care during their undergraduate 1. Emanuel El, Fuchs VR Shortening me about one third of residency-pro- careers is the problem that needs 2. Lyss- Lerman P A, Aagaard E, gram directors representing 10 correction; the solution is not to Loeser H, Cooke M,Harper GMWhat train medical specialties and 21 insti- rush students into residency after ing is needed in the fourth year of medical tutions indicated that interns allowing them even less involve- tors. Acad Med 2009-84-823.9 struggled with the organization ment with patients. 3. Eaglen RH, Arnold L, Girotti JA, et al. The of medical knowledge and the The physician's role on the scope and variety of combined baccalaure application of that knowledge to health care team is evolving. Med 2012:87-1600-8 in the United States. Acad patient care, professionalism re- Teams of physicians, nurse prac- 4. Page RC, Boulger JG. An assessment of lated to assuming responsibility, titioners, physician assistants, and the three-year medical curriculum. ) Me their fund of medical knowledge, pharmacists can develop new 5 Kettel y), Dinham SM, Drach Gw, Barbed and the ability to work without paradigms for delivering higher- RA. Arizona's three-year medical curriculum supervision, among other issues. quality clinical care, even with a a postmortem. JMed Educ 1979, 54: 210-6 The researchers concluded that predicted shortage of primary Do: 10.1056/NEJMp1306457 fourth-year students need to"ex- care physicians. Physicians may copyright e 2013 Massachusetts Medical Society HISTORY OF MEDICINE Autism at 70-Redrawing the boundaries Jeffrey P. Baker, M.D., Ph D his year's revision of the di- autism will lose their eligibility fort to define the syndrome more agnostic criteria for autism is for services. Coincidentally, this sharply. In this respect, it among the most contentious of any year also marks the 70th anni- flects one of the central themes in the new Diagnostic and Statistical versary of psychiatrist Leo Kan- in the history of autism: a debate Manual of Mental Disorders(the fifth ner's first clinical description of over where to set its boundaries edition, or DSM-5), provoking autism in 1943. 1 Though the Kanner did not so much de widespread fears among parents DSM-5 definition explicitly refers fine as portray autism, in the and advocacy groups that children to autism as a spectrum, in im- course of a series of memorable who have received a diagnosis of portant ways it represents an ef- case histories drawn from the ENGLJMED 369: 12 NEJM. ORG SEPTEMBER 19, 2013 1089
n engl j med 369;12 nejm.org september 19, 2013 PERSPECTIVE 1089 3-Year Medical School — Change or Shortchange? safety can impede students’ ability to gain required procedural skills and to develop close relationships with patients. We strongly believe that educators should ensure that each clinical rotation is actually a course in a given discipline rather than simply a 1- or 2-month period of clinical involvement or observation of clinical care. Extensive didactics and the use of new tools for evaluating students’ competence in each discipline should be required components of each clinical clerkship. The fourth year, then, should be a time to hone these new clinical skills and narrow down career choices. Unfortunately, the current fourth year fails to prepare many students for more advanced responsibilities. In a 2009 survey, about one third of residency-program directors representing 10 medical specialties and 21 institutions indicated that interns struggled with the organization of medical knowledge and the application of that knowledge to patient care, professionalism related to assuming responsibility, their fund of medical knowledge, and the ability to work without supervision, among other issues. The researchers concluded that fourth-year students need to “expand their knowledge in both clinical and non-clinical domains.”2 Truncating the medical school experience would make it far more difficult to accomplish that goal. To better prepare students for residency, we believe that more intensive clinical experiences in both outpatient and inpatient settings are needed and that innovative advising and mentoring programs should be created to enhance the transition to residency. Given the growing complexity of medicine, it seems counterproductive to compress the curriculum into 3 years, reducing both preclinical and clinical experiences. The limited opportunity for students to participate meaningfully in patient care during their undergraduate careers is the problem that needs correction; the solution is not to rush students into residency after allowing them even less involvement with patients. The physician’s role on the health care team is evolving. Teams of physicians, nurse practitioners, physician assistants, and pharmacists can develop new paradigms for delivering higherquality clinical care, even with a predicted shortage of primary care physicians. Physicians may need even more advanced education — in health policy, public health needs, clinical research, and medical ethics — in order to lead such teams. But we believe that, at the very least, physicians will succeed as team leaders only if they first attain all the clinical competencies required by the Accreditation Council for Graduate Medical Education. That requires enhancement, not shortening, of medical school. 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 the Perelman School of Medicine, University of Pennsylvania, Philadelphia. 1. Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA 2012;307:1143-4. 2. Lyss-Lerman P, Teherani A, Aagaard E, Loeser H, Cooke M, Harper GM. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med 2009;84:823-9. 3. Eaglen RH, Arnold L, Girotti JA, et al. The scope and variety of combined baccalaureate-MD programs in the United States. Acad Med 2012;87:1600-8. 4. Page RC, Boulger JG. An assessment of the three-year medical curriculum. J Med Educ 1976;51:125-6. 5. Kettel LJ, Dinham SM, Drach GW, Barbee RA. Arizona’s three-year medical curriculum: a postmortem. J Med Educ 1979;54:210-6. DOI: 10.1056/NEJMp1306457 Copyright © 2013 Massachusetts Medical Society. HISTORY OF MEDICINE Autism at 70 — Redrawing the Boundaries Jeffrey P. Baker, M.D., Ph.D. This year’s revision of the diagnostic criteria for autism is among the most contentious of any in the new Diagnostic and Statistical Manual of Mental Disorders (the fifth edition, or DSM-5), provoking widespread fears among parents and advocacy groups that children who have received a diagnosis of autism will lose their eligibility for services. Coincidentally, this year also marks the 70th anniversary of psychiatrist Leo Kanner’s first clinical description of autism in 1943.1 Though the DSM-5 definition explicitly refers to autism as a spectrum, in important ways it represents an effort to define the syndrome more sharply. In this respect, it reflects one of the central themes in the history of autism: a debate over where to set its boundaries. Kanner did not so much define as portray autism, in the course of a series of memorable case histories drawn from the
