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, 2013n engl j med 369;12 nejm.org september 19, 2013 PERSPECTIVE 1087 enced their choice of specialty. Student debt burdens also adverse￾ly affect the economic and racial or ethnic diversity of the medical school population, thereby reduc￾ing the diversity of the physician workforce.5 Concerns about a 3-year path￾way include the sense that though the fourth year is often under￾utilized, it can be a valuable mat￾uration period for many stu￾dents, providing opportunities for research or additional clinical ex￾posure. Related concerns include the potential loss of exploration and enjoyment in the medical ed￾ucation process. Certainly, careful mentoring and monitoring, be￾ginning at the time of matricula￾tion, 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 address￾ing the need for change in the post-Flexnerian era. Shortening brings its own challenges, par￾ticularly the need to assess com￾petency 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 standard￾ized 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 educa￾tion 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 com￾petent care that reduces health disparities. The past three dec￾ades have seen a gradual length￾ening of the training process, driven by isolated decision mak￾ing at the individual program￾matic level. We are at a point of inflection where a coordinated approach spanning the silos of UME, GME, accrediting organi￾zations, and health care delivery systems is critical. We need to train physicians who are com￾mitted 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 physi￾cian requires an extended period (premed, UME, and GME) of both learning and practical experiences. We must ensure the value and ef￾ficiency of our educational efforts, appreciating the various ways in which trainees at all levels will be able to master the requisites nec￾essary 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 Teach￾ing: 1910 and 2010. Acad Med 2010;85:220-7. 2. Emanuel EJ, Fuchs VR. Shortening medi￾cal training by 30%. JAMA 2012;307:1143-4. 3. Smart DR, ed. Physician characteristics and distribution in the US. Chicago: Ameri￾can 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 im￾plications 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 phy￾sicians — perhaps particularly primary care physicians — and reduce the cost of medical train￾ing, without compromising clini￾cal care.1 Data from many years of experiments in shortening medical education, however, sug￾gest that doing so is unwise — a conclusion supported by assess￾ments of the readiness of today’s medical school graduates to as￾sume increased clinical responsi￾bility as they enter residency pro￾grams.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 seek￾ing an M.D. degree, the duration of medical school should not be shortened. There are many examples of past attempts to shorten training