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, 2013PERSPECTIVE 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 enter￾ing medical school class at 67 U.S. schools were students pur￾suing combined B.A.–M.D. de￾grees; 39% of community-based medical schools and 33% of re￾search-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 main￾taining 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 stu￾dents 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 nas￾cent programs aiming to pro￾duce primary care physicians. The reasons articulated in 1970 for embarking on a 3-year curric￾ulum were the same as those cited today: to reduce the cost of education and to increase the number of primary care physi￾cians in a country facing an an￾ticipated physician shortage.5 The causes of the failure of those 3-year programs are not well documented, but some common points have emerged. Both stu￾dents and faculty felt pressured by the compression of material. As many as 25% of students ne￾gated the supposed benefits of an accelerated program by volun￾tarily 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 com￾plete 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 dissatis￾faction with the adequacy of the curriculum. The expansion of medical knowledge since that time, combined with a recent trend toward reducing the pre￾clinical curriculum to 1.5 years, puts even more pressure on the faculty to provide a comprehen￾sive education and on students to gain required knowledge. Other aspects of the failed ex￾periment of 40 years ago reso￾nate in the current proposals. The hope that students would opt for primary care careers was not consistently borne out. Stu￾dents enrolling in some acceler￾ated 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. pro￾grams, but even those numbers were nowhere near the hoped￾for 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 exclu￾sively in outpatient care settings, but its emphasis has largely shift￾ed to inpatient electives,5 through which students seek broad expe￾rience in fields in which they may soon choose a career. Most students spend several months pursuing electives at institutions that rank high among their resi￾dency-site choices. They also spend 2 to 3 months interview￾ing at the hospitals where they would consider pursuing post￾graduate training. If the fourth year were eliminated, these activi￾ties would need to occur during the third year, further compro￾mising clinical education, or would have to be abandoned. Though some observers argue that these efforts to sort through career options and residency pro￾grams lack educational value, they are necessary steps for stu￾dents who are asked to fund their medical education and are therefore entitled to shape the location and nature of their post￾graduate training. In addition, access to global health experiences; instruction in medical ethics, principles of pa￾tient safety, and health policy; and advanced clinical experienc￾es are extremely valuable compo￾nents 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 ad￾ditional 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 resi￾dents, and the current height￾ened focus on efficiency and 3-Year Medical School — Change or Shortchange?