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 1089n engl j med 369;12 nejm.org september 19, 2013 PERSPECTIVE 1089 3-Year Medical School — Change or Shortchange? safety can impede students’ abil￾ity to gain required procedural skills and to develop close rela￾tionships with patients. We strongly believe that educators should ensure that each clinical rotation is actually a course in a given discipline rather than sim￾ply a 1- or 2-month period of clinical involvement or observation of clinical care. Extensive didac￾tics and the use of new tools for evaluating students’ competence in each discipline should be re￾quired components of each clini￾cal clerkship. The fourth year, then, should be a time to hone these new clinical skills and nar￾row down career choices. Unfortunately, the current fourth year fails to prepare many students for more advanced re￾sponsibilities. In a 2009 survey, about one third of residency-pro￾gram directors representing 10 medical specialties and 21 insti￾tutions indicated that interns struggled with the organization of medical knowledge and the application of that knowledge to patient care, professionalism re￾lated 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 “ex￾pand their knowledge in both clinical and non-clinical do￾mains.”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 set￾tings are needed and that inno￾vative advising and mentoring programs should be created to enhance the transition to resi￾dency. Given the growing com￾plexity of medicine, it seems counterproductive to compress the curriculum into 3 years, re￾ducing both preclinical and clinical experiences. The limited opportunity for students to par￾ticipate 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 involve￾ment with patients. The physician’s role on the health care team is evolving. Teams of physicians, nurse prac￾titioners, physician assistants, and pharmacists can develop new paradigms for delivering higher￾quality clinical care, even with a predicted shortage of primary care physicians. Physicians may need even more advanced educa￾tion — 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 Ac￾creditation 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 medi￾cal training by 30%. JAMA 2012;307:1143-4. 2. Lyss-Lerman P, Teherani A, Aagaard E, Loeser H, Cooke M, Harper GM. What train￾ing is needed in the fourth year of medical school? Views of residency program direc￾tors. Acad Med 2009;84:823-9. 3. Eaglen RH, Arnold L, Girotti JA, et al. The scope and variety of combined baccalaure￾ate-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 di￾agnostic 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 anni￾versary of psychiatrist Leo Kan￾ner’s first clinical description of autism in 1943.1 Though the DSM-5 definition explicitly refers to autism as a spectrum, in im￾portant ways it represents an ef￾fort to define the syndrome more sharply. In this respect, it re￾flects one of the central themes in the history of autism: a debate over where to set its boundaries. Kanner did not so much de￾fine as portray autism, in the course of a series of memorable case histories drawn from the