Who Will Study Medicine in the Future?

One year ago, an AAMC working group charged with examining educational costs and student indebtedness issued its final report. In that document, the group made clear the seriousness of the issues it had been asked to analyze:

This report has demonstrated, we hope convincingly, that, unless significant changes are made, careers in medicine may not be affordable or attractive within the next few decades, and that applicants from lower socioeconomic groups may choose not to pursue careers in medicine because of their concerns about educational costs.¹

In my view, the academic medicine community must develop a much greater sense of urgency about the need to effectively address the group’s concerns. I do not believe that more time is needed to study the issues involved. And I assert that there is only one realistic solution for addressing them (see below). Accordingly, I believe the time has come for the community to take action. Let me explain.

To begin, data already exist showing that the cost and duration of a medical education deter some potential medical school applicants from pursuing a career in medicine, and that these factors disproportionately affect students from families in lower socioeconomic groups.² Indeed, one simply has to examine the distribution of medical school matriculants drawn from various socioeconomic groups to see that this must be the case. Sixty percent of medical school matriculants come from families in the top quintile of earners. Given this, it is clear that the cost and duration of a medical education have already adversely impaired medical schools’ efforts to achieve greater diversity within their student bodies and, thus, within the profession as a whole. The importance of achieving these goals provides a sufficient reason for moving forward now in adopting a solution that will address those problems.

But in addition, consider how those problems—the cost and duration of a medical education—will probably affect medical schools’ efforts to increase enrollments. The AAMC will likely call on its members once again to increase enrollments, perhaps to as high as 30% (an additional 5,000 matriculants per year) in response to projections that the country will soon experience a significant shortage of physicians. If the cost and duration of a medical education continue to deter potential applicants from applying to medical school, will schools be able to meet that target? Given what we know about historical trends in the size of the applicant pool, and the impact that gender, race, ethnicity, and family income are likely to have in coming years, it seems almost a foregone conclusion that the number of highly qualified applicants will not be adequate unless the factors that deter potential applicants from applying are successfully addressed.^3,4

I assert that there is only one realistic way to do this: the length of the medical school curriculum must be shortened by one year.

Now, there is nothing novel about the idea that the curriculum should be shortened to decrease the cost and duration of a medical education. Robert Ebert, former dean of the Harvard Medical School, and Eli Ginzberg, one of the country’s preeminent health economists, proposed exactly that in a landmark article they published in 1988.⁵ In that article they argued that the curriculum should be shortened by integrating the last year of the medical school curriculum into the initial years of residency training to create a coherent clinical education continuum. They pointed out, for example, that by taking this approach the total duration of training required to become a general internist, a family physician, or a pediatrician could be decreased from seven years to six years.

There are many other experiences that suggest strongly that a three-year curriculum would suffice for most students. For example, in the early 1970s almost one fourth of the medical schools in existence at the time established three-year programs in response to financial incentives provided by federal manpower legislation. Those programs were discontinued in the mid-1970s largely because basic science faculty did not believe they provided an adequate time to teach their disciplines. It is important to note, however, that there was no objective evidence that the programs disadvantaged the students who completed them.⁶ And in order to test whether the proposal advanced by Ebert and Ginzberg would work, the American Board of Internal Medicine and the American Board of Family Practice established pilot programs in a small number of sites that allowed students to complete the requirements for board certification in only six years. The pilots were discontinued only a few years ago, largely because it was not possible to generalize the model. But once again, it is important to note that there was no convincing evidence that the programs disadvantaged those who completed them.

The favorable results of those experiences are really not too surprising. Given that most schools devote a considerable amount of the fourth year to electives, it seems logical that the core material required of all students could be offered within a three-year period. And those who may feel that three years is not an adequate period of time for presenting a core curriculum should ask themselves several questions, such as: How is it that Duke accomplishes this in only two years? And how is it that several other schools allow students to complete all of the course work required to receive both the MD degree and a second degree (MPH, MHA, etc.) in a total of four years?

Shortening the curriculum by one year would clearly decrease the duration of a medical education. But would this be the most effective way for reducing the financial burden of a medical education? In their research report appearing in this month’s journal, Dorsey and his colleagues show that reducing the medical school curriculum by one year would be the most effective way to decrease the overall cost of a medical education, the impact that the cost has on student indebtedness, and its impact on a physician’s long-term financial status.⁷ But what effect would this have on the costs medical schools incur in conducting their educational programs? In the early 1990s, Bob Jones and David Korn, two members of the AAMC’s executive staff, conducted a major study of the cost of medical education. Here is a telling quote from their report of that study:

Only by the net reduction of the medical school curriculum—for example, by popularizing the concept of the combined six- or seven-year college and medical school curriculum, or by combining the fourth year of medical school with the first year of residency, as was proposed by Ebert and Ginzberg—might costs truly be reduced.⁸

I believe the time has come for medical schools to develop a more flexible curriculum structure—one that would allow students who wish to shorten the duration of a medical education by one year to do so. This approach is completely consistent with recommendations included in the report issued in 2004 by the Ad Hoc Committee of Deans.⁹ Students who opt for a shortened course of study would not only decrease the duration of their medical education, they would also realize the financial benefits of doing so. And by providing this option, one would hope that medical schools would attract not simply more applicants, but applicants that more closely reflect the diversity of our country’s population. Those who might find this idea highly unacceptable should recall the warning set forth by the AAMC working group:

…unless significant changes are made, careers in medicine may not be affordable or attractive within the next few decades.

Michael E. Whitcomb, MD