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For-Profit Undergraduate Medical Education: Back to the Future?

Shomaker, T Samuel MD, JD

doi: 10.1097/ACM.0b013e3181c865b8
Flexner Centenary: Article

One hundred years ago, Abraham Flexner wrote a report that profoundly influenced U.S. medical education. His conclusion—that medical degree (MD)-granting education programs should occur in not-for-profit universities and include hands-on laboratory and patient care experiences in teaching hospitals and clinics—led to the creation of the current model of U.S. MD education. Although this model has served the United States well, it is lengthy and costly. As the United States struggles to deal with a growing shortage of physicians, other models of medical education, including osteopathic medicine and offshore, MD-granting schools, have increased production of graduates. New private colleges of osteopathic medicine, including one accredited proprietary school, are nimble, cost-effective competitors for MD-granting schools. Do these schools portend the establishment of a U.S. for-profit medical education sector in the same way that proprietary universities have become well established in higher education? How should MD medicine respond? Can and should MD educators shorten the time needed to produce a fully trained MD-holding physician? How can MD educators make the training process shorter and less expensive to respond to the nation's physician shortage while maintaining the appeal of MD careers and without compromising educational quality? Models of shorter, less expensive pathways to earning an MD exist and have proven effective. Now is the time for MD educators to debate whether they should apply these pathways more widely. Six recommendations could help realize the goals of shortening and making less costly the training of MD physicians in the United States.

Dr. Shomaker is professor, Department of Anesthesiology, University of Texas Medical Branch Galveston, Galveston, Texas, and dean, University of Texas Medical Branch Austin, Austin, Texas.

Correspondence should be addressed to Dr. Shomaker, University of Texas Medical Branch Austin, University Medical Center Brackenridge, 601 E. 15th Street, Suite C2.160, Austin, TX 78701; telephone: (512) 324-8381; fax: (512) 324-7051; e-mail:

What is the largest university in America? Ohio State? Arizona State? I'll give you a hint; it is the only university that has its name on a National Football League stadium. The University of Phoenix (UOP) has over 362,000 students and 20,000 faculty at nearly 250 locations across the United States.1 In fiscal year (FY) 2008, UOP received more federal student financial aid ($2.8 billion) than any other U.S. university.2 UOP is a subsidiary of the Apollo Group, which, despite the severe economic recession, posted impressive results for FY 2008. Apollo had a net income of $477 million on revenues of $3.1 billion, a 15% increase over FY 2007; enrollment in the company's degree programs also increased 15%.1 Apollo became a publicly traded company in 1994, is currently listed on the NASDAQ exchange (Ticker: APOL), and is an S&P 500 corporation. UOP, which is accredited by the North Central Association Commission on Accreditation and School Improvement, offers more than 100 on-campus and online degree programs, including a master's of science (MS) in nursing, an MS in nursing for nurse practitioners, an MS in psychology, and master's and doctoral degrees in health administration.3 Apollo group is one of a growing number of U.S. proprietary (i.e., for-profit) higher education companies that include DeVry Incorporated, Career Education Corporation, and Education Management Corporation. (By the way, the UOP paid the Arizona Cardinals $154.5M for 20-year naming rights for the University of Phoenix Stadium in Glendale, Arizona.4)

Did you know that an accredited proprietary medical school is operating in the United States, the first founded in this country since 1930? Rocky Vista College of Osteopathic Medicine (RVCOM), located in Parker, Colorado, has received provisional accreditation from the American Osteopathic Association's Commission on Osteopathic College Accreditation.5 The school admitted 160 students from a pool of over 2,000 applicants for its initial class in the 2008–2009 academic year and 162 students from a pool of nearly 3,200 applicants for the 2009–2010 academic year. The school has received over 4,000 applications for next year's class.6 Its stated purpose is to address the shortage of primary care physicians in Colorado.7 Two individuals own the school, which is chartered in Colorado as a for-profit corporation, Rocky Vista LLC (limited liability corporation).

In the Caribbean, 56 medical schools are now in operation, 22 (40%) of which have been established since 2000.8 A 2008 report estimated that approximately 30 of these schools are for-profit.9 Many of these schools cater to students, both U.S. and foreign nationals, who hope to enter U.S. graduate medical education (GME) programs so that they can practice medicine in the United States. Eleven years ago, only 424 Americans who studied abroad received certification from the Educational Commission for Foreign Medical Graduates to begin the U.S. licensure process; in 2007, that number rose to 1,360.9 In 2008, 2,064 certificates were issued to U.S. citizens, with the largest numbers going to graduates of medical schools in Dominica (583), Grenada (422), the Netherlands Antilles (308), and the Cayman Islands (112).10 Review of the quality of these schools is uneven. In some countries, such as Dominica and Cuba, government agencies oversee medical schools. A regional accreditation association, the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP), has been established, but as of October 2009, only seven schools in the region had subjected themselves to accreditation reviews, and only four had received full accreditation.11

The older, more established for-profit medical schools in the region, such as Ross University in Dominica and St. George's in Grenada, have been in existence for 20 years or more, and both have recently received full accreditation by CAAM-HP. They claim to have admissions standards and educational programs of quality comparable with accredited U.S. medical schools. Ross, established in 1978, was acquired by DeVry Incorporated, a for-profit educational company, for $310M in 2003.9 Ross has over 6,500 graduates, and 5,000 of them are practicing in the United States. It has a class size of approximately 400 students per year, more than any U.S. medical school, and Ross' tuition is $29,000 year.8 Ross claims to offer over 5,000 clinical rotation opportunities at more than 70 institutions nationwide, more (it claims) than “any other medical school in the world.”12 Ross' medical students complete the first two years of their education in Dominica and then disperse across the United States for years 3 and 4. St. George's has a total of 7,390 graduates and 3,982 currently enrolled students (including 3,800 in the four-year medical degree program).13

In contrast to the established history and track record of Ross and St. George's, some of the newer Caribbean programs have lax admission standards, little or nothing in the way of facilities, and small, poorly trained faculties. Some conduct most of their classes over the Internet, so students do not even have to be present on campus to pursue their degrees. Establishing a new school in some Caribbean countries is simply a matter of acquiring a business license in the country where the school will be. This allows the school to be listed on the World Health Organization medical schools directory, and that, in turn, permits graduates to take the United States Medical Licensing Examination (USMLE).9 Further, the success rates of students produced by Caribbean schools on USMLE varies widely; for example, USMLE Step 1 student pass rates ranged from 19.4% to 84.4% across the countries of the region.8 Nonetheless, the trend toward establishing new schools in the region is continuing unabated; plans to establish additional for-profit schools in Anguilla, Montserrat, and St. Kits are moving forward.8

Does the growing role of for-profit medical education spell the beginning of the end of the current U.S. model of medical degree (MD)-granting education? Is it a temporary aberration driven by the growing physician shortage in the United States? Or does the future of medical education lie somewhere in between?

Traditional public and private not-for-profit universities and colleges have adjusted to competition with for-profit institutions, and the for-profit sector has staked out a solid niche in the higher education market. Despite a stormy beginning that occasioned heated debate, for-profit hospitals and health systems are now accepted without question and seem destined to be a permanent fixture in the U.S. health care system. Would having for-profit, MD schools in the United States be such a bad thing? To answer this question, providing some historical context may be useful.

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Historical Context

The first medical school in North America dates back to around 1765, when a chair in the theory and practice of medicine, affiliated with the Philadelphia Hospital, was established at the College of Philadelphia.14 Thus, the first U.S. MD medical school was a part of an established university and conducted its teaching in a hospital environment. In 1791, this institution evolved into the University of Pennsylvania. Other early university-based schools followed at Columbia, Harvard, and Yale. Soon after the turn of the 19th century, a new type of school was founded in Baltimore: the first for-profit medical school. Over the ensuing years many additional schools, both university-based and proprietary, were founded across North America. In the early years of the 20th century, 155 medical schools were in operation in the United States14 (considerably more than the 131 that exist today!). Only about 50 of these schools were truly university-based institutions; the remainder were either independent, fully for-profit schools or proprietary institutions nominally associated with a local college or university.14 Lax or minimal admissions standards characterized the for-profit schools; many did not even require the completion of high school—let alone college—and the only qualification for admission was ability to pay tuition. Instruction was completely didactic and generally consisted of two semesters of lectures delivered by faculty who pocketed the fees paid by students. Some schools did not require their students to take examinations, and at others, perfunctory testing sufficed. No hands-on work in either the laboratory or the hospital setting was available for students. No licensing boards existed, so the issuance of a diploma from one of these schools allowed the graduate to begin medical practice.15 Not surprisingly, given the shortcomings of their training, U.S. medical graduates of this era failed to incorporate advances in the scientific understanding of health and disease into their medical practices, contributing to the relatively poor state of medical care in the country.

In 1893, Johns Hopkins University School of Medicine, based on a German university model, was founded in Baltimore, Maryland. In an unprecedented move, the school required a bachelor's degree for admission. It also established a rigorous curriculum, including required courses in anatomy and pathology, which were conducted in laboratory settings and gave the students an excellent grounding in the scientific foundations of medicine. Clinical rotations in the school's teaching hospital and clinics ensured that students had experience caring for patients under faculty supervision before venturing out to establish their own independent practices. Several other established schools emulated Johns Hopkins' precedent, including Harvard, Western Reserve, Cornell, Stanford, and the University of California at Berkeley.14 However, many existing schools, especially the for-profits, maintained their traditional lecture-based approach to medical education.

Enter Abraham Flexner, an American educator trained at Johns Hopkins University. He founded a private school in Louisville, Kentucky, to test his ideas on education, which included an emphasis on small class sizes and hands-on teaching. In 1908, Flexner published The American College: A Criticism, a book critical of prevailing practices at universities of the time, including the overuse of large group lectures.16 Following publication of this book, the Carnegie Foundation commissioned Flexner to do a study of medical education in the United States. He took to his task with great thoroughness; in the process of writing his report, Medical Education in the United States and Canada (1910),14 he visited all 155 U.S. medical schools and compiled data on their admissions standards, curricula, financing, faculty, and facilities. His report highlighted a number of major shortcomings in existing educational practice. First, he noted “an enormous overproduction of uneducated and ill-trained medical practitioners.” Second, Flexner felt that this overproduction was “due in the main to the existence of a very large number of commercial schools.” Third, he believed that “a hospital under complete educational control is as necessary to a medical school as is a laboratory of chemistry or pathology” and that for-profit schools did not supply either laboratory or hospital facilities. He concluded that the country would be well served by having fewer medical schools producing a smaller number of better-trained graduates. He advocated both moving medical education to the university-based model exemplified by Johns Hopkins and closing proprietary schools.14

Flexner's report was a seminal event in the history of American medical education. It has set the course of medical education in the United States for 100 years.15,17 Proprietary medical education died out; the last for-profit medical school closed in 1930. U.S. medical education went from being wholly inadequate to being the finest in the world, and medical practice improved in parallel. The method of education Flexner advocated took root and continues to this day; U.S. MD medical schools are universally components of not-for-profit universities and feature curricula that include lectures, laboratory experiences, and hands-on patient care in teaching hospitals.

No doubt, if he were alive today, Abraham Flexner would be concerned about the trend in the direction of proprietary medical education. But given the challenges facing the health care system of the United States, including a growing shortage of physicians, declining interest in primary care, a maldistribution of doctors impacting urban core and rural areas, growing concern over the number of un- and underinsured patients, the high costs of health care, and the less-than-optimal quality and safety of care provided, U.S. medical educators must ask whether the current model of MD medical education still serves the country well.

The existing paradigm of MD education has an established track record of producing well-trained physicians; however, the U.S. system is far from perfect. The MD training continuum is both exceedingly lengthy (a minimum of seven years) and exceedingly costly (about $100,000 per trainee per year).18,19 The education of MD students, conducted as it is in large teaching hospitals, occurs in an environment steeped in research and tertiary/quaternary patient care. This is a rich educational milieu, but one could not imagine a setting with higher overhead expenses. Further, teaching medical students has often been a secondary pursuit of faculty members who receive remuneration based primarily on the grant funding they generate and/or the number of patients they see. The length of the current curriculum for medical students, residents, and fellows represents a balancing act between the mass of information that educators have decided trainees should absorb and the costs—in terms of both money and time—trainees incur. Given where U.S. health care stands today, is this balance still set appropriately?

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The Rise of For-Profit Higher Education

A parallel to the current state of medical education existed in higher education several decades ago. In the late 1970s, computers were in their infancy and the baby boom generation was just turning 30. Higher education was confined to place-based, not-for-profit colleges and universities. Dr. John Sperling, a Cambridge-trained economist and professor, concluded that technological development, economic forces, and demographic trends would combine to create demand among working adults for further education and training.20 Sperling created the UOP in 1976 in Phoenix, Arizona, to serve that demand. He pioneered new methods in program design, such as distance learning; highly standardized, centrally developed curricula; and the employ of full-time professionals in various fields as part-time teachers, in order to engineer educational programs that catered to the needs of working adults. Today, approximately 75% of UOP's students are enrolled in online courses. These students are older and more likely to be from minority backgrounds than students at other universities (UOP students average 33 years of age in undergraduate, and 36 years of age in graduate programs, and about 25% are African American and 13% are Hispanic; by contrast, only about 25% of students at U.S. degree-granting institutions are over 30, and minority enrollment in 2007 was 13% African American and 11% Hispanic).1,21 Ninety-five percent of UOP's faculty are part-time, which decreases salary and benefit costs. Undergraduate tuition is affordable for more people at about $12,000 per year compared with approximately $26,000 for typical private and $7,000 (in-state) and $18,500 (out-of-state) for typical public universities.22 Contact time per course at UOP is about 22 hours, as opposed to the typical university standard of 40 hours, allowing students to complete degree requirements and enter the workforce in less time. UOP's business model uses office buildings located near major freeways as its “campuses” for convenient access by students. Still, despite the many innovations pioneered by UOP, there is an undercurrent suggesting that the profit motive influences institutional behavior in undesirable ways. Accusations of improper student recruiting and financial aid practices, as well as allegations of making misleading representations to investors (some of which are currently in litigation), have plagued UOP/Apollo.23

Other for-profit companies have followed the lead of UOP/Apollo, and the for-profit sector now constitutes a small but growing part of U.S. higher education, accounting for around 4% of the $373 billion postsecondary education market and enrolling around 1.3 million of the 18 million postsecondary students (2005).24 In the current U.S. economic downturn, for-profit universities have fared well, with enrollment growth of 14% and revenue growth of over $10 billion or 13% in FY 2008.25 For-profit higher education is here to stay, and traditional colleges and universities have had to adapt to their new competitors. This they have done with varying degrees of success. For example, many not-for profit universities now offer online undergraduate and graduate programs, catering to the adult learner market.

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A Physician Shortage Is Driving Expansion of Undergraduate Medical Education

U.S. medical education stands at a crossroads not unlike that facing higher education in the immediate pre-UOP era. The physician shortage facing the nation is driving an expansion of medical education unseen since the 1970s.26 Part of this push has been prompted by the Association of American Medical Colleges (AAMC), which in 2006 revised its position on the physician workforce and challenged the medical education community to increase medical school enrollment 30% by 2015.27 Of 131 U.S. medical schools, 108 have expanded or plan to expand the size of their classes. First-year MD enrollment is up 5% from 2002 and now numbers 17,300 students.28 Most of this growth has resulted from expansion of existing schools, but the national accrediting body for medical schools, the Liaison Committee on Medical Education (LCME), has accredited five new schools, granted candidate status to one other school, and received applications for accreditation from three more.29 By 2012 the AAMC is projecting that first-year enrollment will be 19,500, 18% above 2002.30

Osteopathic medical education is also experiencing a period of dynamic growth, expanding faster than MD medicine; enrollment is expected to double between 2002 and 2015, to around 6,000 annual graduates.28 Twenty-five colleges of osteopathic medicine are currently operating in the United States; six new schools have been founded since 2003, and an additional four were founded between 1992 and 2003.30 All the osteopathic schools established since 1992 are private. Historically, osteopathic medical education is based on a different philosophical approach than MD education and emphasizes holistic patient care, manipulative medicine, and primary care. However, in recent years, with the advent of the new private schools, declining interest in primary care among osteopathic graduates, and a trend of osteopathic graduates pursuing MD GME, significant changes have occurred in osteopathic education.31

Compared with MD schools and with the older osteopathic schools, the private osteopathic colleges that have been established since 1992 are mostly freestanding health sciences universities (with more than one health education program) not affiliated with larger universities. They are characterized by large class sizes (several have expanded into more than one campus site), heavy dependence on student tuition dollars, small numbers of full-time faculty, little research activity, small or no GME programs, heavily decentralized clinical curricula, use of multiple and often remote hospitals as training sites, and the absence of a clinical practice plan.32 In short, these colleges of osteopathic medicine are a new model of medical education with a far smaller cost structure than MD education programs. They are being established in response to market signals that the United States is facing a physician shortage; they are able to respond to that shortage in a nimble and cost-effective way. The founding of RVCOM as a for-profit educational institution is simply an extension of that response to market pressure. Given demand created by the current shortage and the precedent of RVCOM, the osteopathic medical education sector will likely come to resemble the higher education environment more generally; that is, it, too, will be characterized by the coexistence of both not-for-profit and for-profit institutions.

The for-profit MD schools cropping up with growing frequency in the Caribbean are responding to the same market demands (those relating to the perceived U.S. physician shortage) as the osteopathic schools. Mostly for-profits, these schools represent an investment opportunity for their owners and shareholders. As long as a shortage in the market for physicians prevails, investors can make money expanding offshore, for-profit schools that cater to those who seek to practice in the United States.

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For-Profit MD Education in the United States?

Given that for-profit institutions are now established both offshore and in osteopathic medicine, is for-profit MD medical education in the United States a realistic possibility? LCME accreditation standards, although stringent, do not prohibit for-profit schools. Standard IS2 states, “A medical school should be, or be part of, a not-for-profit institution legally authorized under applicable law to provide medical education leading to the MD degree.”33 In LCME accreditation parlance, a should is not a must. Thus, the door is ajar for a for-profit that could meet all of the other standards. Notably, in the late 1990s, at least two for-profit MD schools attempted to set up campuses in the United States. In 1999, Ross University proposed a campus in Casper, Wyoming, that would have had staff and facilities sufficient to accommodate a class size of between 600 and 1,000 students.34 Plans were later dropped following opposition to allowing Ross, an unaccredited medical school, to operate in the United States. Kizgezi International School of Medicine of Uganda attempted to establish a U.S. campus in Washington state but was thwarted when the University of Washington declined to rent the institution educational space.35

Instead of remaining complacent, those of us who believe in the U.S. MD educational model must ensure that our internal house is in order. If not-for-profit MD medicine does not evolve to address some of the concerns leveled at it during this time of physician shortages, other models will challenge the previously secure place in the U.S. medical education system that MD degree schools have occupied for the last 70 years. This is especially true now that health system reform has become an issue of pressing national concern. To effectively participate in and help lead health system reform, physicians will need new skills that must be incorporated into the MD curriculum. These include using informatics to improve patient safety, deploying proper care processes and using resources appropriately, applying systems-based approaches to population and public health, functioning effectively as members of interdisciplinary teams, and understanding the cultural nuances of caring for an increasingly diverse patient population. Thus, now is the time for a new Flexner Report that will take a hard look at how we educate MD physicians, to see if innovation can reduce training time, educational expense, or both—while still preserving quality and adding the content mandated by today's practice environment.

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How Should U.S. MD Education Respond?—Recommendations

At the risk of being unduly provocative, I present six strategies worth considering.

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Recommendation 1.

Experiment with undergraduate medical school curricula that shorten the time to graduation by at least one year.36 These experiments should not just condense the existing curriculum into a shorter span of time but should thoughtfully reexamine the curricular elements needed for modern medical practice. The most effective approach to this problem may be to view the educational continuum as a whole. This may involve reevaluating what prerequisite knowledge students should bring to medical school as well as what subjects are more appropriately dealt with in graduate (or even continuing) MD education.

Several medical schools have already successfully implemented curricula that free an entire year for research; for example, the Duke University MD curriculum covers the basic sciences in year 1, provides basic clinical rotations in year 2, requires a third research year, and finishes with advanced clinical rotations in year 4.37 Thus, Duke has created a curriculum that covers the core MD curriculum in three years. As the fourth year in most medical schools is largely elective, could MD educators experiment with curricula that would graduate students in three years and get them into residency training at least one full year sooner? This idea is hardly novel. In the 1970s, 10 of 112 U.S. medical schools, spurred by a growing physician shortage and encouraged by a federal payment of $2,000 for each student that graduated in three years,38 implemented required three-year curricula; 47 others provided both a three- and a four-year option.39 Most of these experimental curricula condensed basic science instruction into only one year by eliminating vacations, extending class hours, and covering the same amount of material that the two-year basic science curriculum had covered. The resulting stress on students and faculty alike led to the abandonment of the three-year approach by the end of the decade.40

Fast forward to the present in which osteopathic medicine is leading the way in experimenting with a three-year medical school curriculum in the United States. In 2006, Lake Erie College of Osteopathic Medicine implemented a three-year medical school program for a group of students who desire careers in primary care medicine.41 Curriculum planners distilled the school's traditional four-year curriculum into a coherent three-year program, adding some material needed for a primary care emphasis and deleting other coursework. In Canada, among other innovations, the University of Calgary has successfully pioneered a three-year curriculum for all students regardless of career path.42 A different variation on the theme of a shorter MD curriculum is represented by schools in the United States that have successfully adopted the European approach to medical education. For example, the University of Missouri–Kansas City has a 35-year record of success with a 6-year combined baccalaureate and MD curriculum that cuts 2 full years off the training.43

Also, pilot projects in the 1990s tested a combined fourth year of medical school/internship model in family medicine and internal medicine. Participants achieved scores comparable to those in conventional training programs on standardized tests and clinical evaluations, but the programs were dropped because of Accreditation Council on Graduate Medical Education requirements that trainees possess an MD before beginning residency.36,44 Issues with eligibility for licensure, health plan credentialing, and board certification, as well as loss of Medicare GME reimbursement, stand as potential obstacles to revisiting this approach.

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Recommendation 2.

Examine the feasibility of shortening residency/fellowship training by allowing earlier career differentiation of trainees, creating customized training programs for residents or fellows with particular career interests, and/or combining the fourth year of medical school with internship.

Residency education is another area in which MD educators could test the time economies of the training process. As one commentator succinctly puts it, “training simply takes too long.”45 Family medicine practitioners have discussed a two-year residency paradigm focused primarily on developing doctors for ambulatory practice.46 Plastic surgery has collaborated with general surgery to create a combined five-year training program that eliminates two years from the previous five-plus-two approach.47

As with undergraduate MD education, current accreditation, licensure, and funding processes may all present barriers to shortening GME, but evidence from prior experiments already shows that the quality of an abbreviated GME product can be equal to that of a traditional program if a thoughtful approach is taken.

Shortening either medical school or residency—or both—would cut down on educational expenses for both trainees and the institutions that train them. A recent study concluded that shortening the training time of physicians by one year would result in cost savings to trainees between $160,000 and $230,000 in today's dollars.48 Lower debt burdens might make primary care careers more appealing to some trainees. Cutting down on training time would also shorten the production pipeline and help to relieve the physician shortage facing the United States.

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Recommendation 3.

Create pilot programs to examine the feasibility of moving toward competency-based completion requirements and away from time-based educational program requirements such as LCME ED-4 (i.e., “The program of medical education leading to the MD degree must include at least 130 weeks of instruction”) and Accreditation Council for Graduate Medical Education internal medicine program requirement IV.A.1a (i.e., “An accredited residency program in internal medicine must provide 36 months of supervised graduate medical education”). While complex in design and implementation, this approach holds the most promise for streamlining and customizing professional education in the future.

When a trainee demonstrates satisfactory achievement in the competencies established by faculty for the basic sciences, clinical sciences, graduation, or residency training, he or she would be permitted to advance to the next level of training. This approach might well result in shortening the training time for at least some trainees. Of course, a completely competency-based curriculum poses many logistical, financial, and regulatory issues that would have to be addressed, but, as educational technology becomes more advanced, these issues become manageable.49

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Recommendation 4.

Disperse trainees to less costly outpatient training venues in appropriate circumstances.

MD educators should carefully examine not only the costs of medical education but also the appropriate venue for training.50 For those MD students who desire a career in primary care or clinic-based medicine, training should take place largely in the ambulatory setting. The tertiary care medical center should be used more exclusively for those trainees pursuing specialties in which physicians deliver the majority of patient care to inpatients. Although some specialties, such as internal medicine, have hesitated to embrace early differentiation of trainees, preferring to expose all residents to a consistent body of core training experiences spanning both inpatient and ambulatory settings,51 the trend toward specialization in either hospital-based medicine or ambulatory practice is growing more and more common across many medical specialties and seems highly likely to continue.52 Appropriately siting training could reduce training-related expenses to make the MD educational process more cost-competitive.

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Recommendation 5.

Experiment with the increased use of nonphysician educators and educational technology to decrease medical education labor costs.

The increased use of nonphysician educators in MD education is another potential cost-saving innovation, especially in the context of a growing physician shortage.53 Nurse practitioners, physician assistants, and nurse midwives have all been successfully employed as medical student and resident educators, especially in clinical teaching settings. In addition, a growing number of master's degree programs in medical education and health care education are producing educators who are contributing to medical education programs in the United States and around the world.53 Finally, advances in educational technology, including computer-aided instruction, virtual patients, and human patient simulation, are making a growing contribution to all types of medical education, both as an adjunct to or a replacement for more traditional lectures and small-group seminars.54 These new applications are creating more and more opportunities for customized learning that can surely replace at least some face-to-face class time, thus saving on faculty time and salaries.

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Recommendation 6.

Actively encourage and adequately compensate medical school faculty who teach students and residents.

At some of our MD degree schools, medical student and even resident teaching is not accorded the importance it deserves.55 MD medical leaders should make sure that the teaching mission of schools is reemphasized so that students and residents feel valued and those who teach them are appropriately prepared and recognized for their skill and commitment. Trainees can easily sense when they are an afterthought. Teaching by skilled and experienced faculty role models creates a positive educational environment in which students and residents thrive.55 The learning experiences created by master teachers have a lasting impact on students and residents and serve as a strong argument in favor of the educational approach used to train MD medical students and residents.

Although reciting that medical teaching does not always get the emphasis it deserves has become almost trite, and although some schools have acted to better recognize and reward those who teach, it bears repeating that medical school leaders should reexamine faculty salary and promotion standards and processes. The successes and contributions of the teaching faculty are of equal value, and deserve as much celebration, as those of productive research and clinically oriented faculty.

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In Sum

Perhaps we are going to go back to the future in U.S. MD education. Some additional competition, in the forms of continued expansion of osteopathic medicine, additional growth in offshore MD programs, and the potential establishment of for-profit MD schools in the United States—or some combination of these scenarios—seems likely. Although we MD practitioners and educators may not be happy about these developments, they may well happen regardless of what we think of them. The challenge facing MD medicine is to evolve its educational continuum to produce high-quality graduates with the right skills in the shortest and least expensive manner. Through educational and curricular innovation and scholarship, we will ensure the valued role of the MD education model in the training of physicians for the United States. This is a goal that Abraham Flexner would recognize as legitimate—protecting the public interest by producing the best physicians possible to care for the people of the United States now and in the future.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

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