Most medical schools continue to follow the traditional Flexnerian model of medical education, proposed over 100 years ago, with two years of basic science instruction followed by two years of clinical training.1 In the 1970s, 25% of U.S. medical schools began offering 3+3 programs with three years of medical school plus three years of residency.2 These programs waned over time, primarily because their model included residency trainees who had not received MD degrees (the medical degree was awarded after the first year of residency, thereby delaying licensure), making the logistics of residency training challenging. In addition, many of the programs were intense, compressing most of the four-year curriculum into three years, causing stress among trainees.3 McMaster University Michael G. DeGroote School of Medicine and University of Calgary Cumming School of Medicine in Canada have awarded medical degrees after three years to all students for decades. In the last decade, we have seen a resurgence of interest in three-year MD pathway programs in the United States. Some of the U.S. interest originates from the 2010 Carnegie report, which recommended that medical education become more individualized, including the possibility of fast-tracking within and across all levels of training.4 Recent support for accelerated pathways points towards mounting student debt, the progressive lengthening of graduate medical education (GME), and the questionable value of the fourth year of medical school for many students as a supporting rationale for shortened training.5–7
A 2014 survey of U.S. medical school deans found that 35% of medical schools have or are considering the development of a three-year MD pathway program.8 These new three-year pathways challenge long-standing historic paradigms and have stimulated a national dialogue to reexamine the content and length of medical education. In addition, new competency-based models of education would permit shortening of medical education for students who are deemed competent in less than four years. A recent pair of New England Journal of Medicine point–counterpoint articles described the opposing views of accelerated medical pathway programs.6,9
Proponents of accelerated pathways highlight the reduction of student debt and the desirability of acceleration for a subset of students who are seeking rapid entry into the workforce as clinicians or clinician–scientists with the ability to impact the worsening physician shortage.6 Some accelerated programs that focus on primary care also serve a social mission to provide increased physician access to rural and underserved populations. Accelerated pathways can provide individualized experiences for students who know what they want to do in medicine. Many programs link accelerated graduates to their own residency programs, allowing them to follow and assess learners across the undergraduate medical education (UME)–GME continuum. The greatest opposition to shortening training is the concern of producing physicians that are deemed less competent. Studies published in the 1970s dispute this notion and show no major difference in performance of three-year and four-year students.3,10,11 A review of McMaster graduates’ experience showed that graduates’ performance on standardized exams, preparation and performance in residency, and ability to obtain residency positions were comparable to those of four-year graduates of U.S. and Canadian medical schools.12 Other concerns regarding accelerated programs include those related to student wellness (fatigue, burnout, dissatisfaction); faculty dissatisfaction with the speed of the curriculum given the expansion of medical knowledge over time; and loss of instruction in health policy, patient safety, and medical ethics.9 The value of the fourth year is also being questioned. For many students, the fourth year is a time to synthesize the experiences of the clerkship year and to explore career options, but with the burdensome residency application process, the fourth year’s educational focus has been reduced as the majority of time is spent on “audition rotations” and residency program interviews.7
A recent article described the merits and challenges of three-year medical school curricula but did not provide curricular or administrative details.2 In 2015, with support from the Josiah Macy Jr., Foundation, eight medical schools with three-year medical pathway programs came together to form the Consortium of Accelerated Medical Pathway Programs (CAMPP). As of 2016, all CAMPP schools have current students enrolled in an established track that reduces the length of training in calendar months as well as students who are already matriculated or who will matriculate this year. The eight CAMPP medical schools are McMaster University Michael G. DeGroote School of Medicine; Medical College of Wisconsin (MCW)–Green Bay and Central Campuses; Mercer University School of Medicine (MUSM); New York University (NYU) School of Medicine; Penn State College of Medicine; Texas Tech University Health Sciences Center (TTUHSC) School of Medicine; University of California, Davis (UC Davis) School of Medicine; and University of Louisville School of Medicine. The programs vary in size and medical specialty focus, but most capitalize on training and assessing competency across the UME–GME continuum and include conditional acceptance into an affiliated residency program.
CAMPP convenes schools across North America to share best practices, challenges, and potential solutions to creating accelerated programs across a spectrum of academic settings. In this article, we include an overview of each CAMPP program with attention to admissions, curriculum, financial support, and regulatory challenges, and we describe outcomes for recent CAMPP graduates.
Three-Year MD Programs: Descriptions of Participating Institutions Within the Consortium
Since its inception in 1969, the MD program at the Michael G. DeGroote School of Medicine has been a 3-year program for all students. The core pedagogies include problem-based learning and patient exposure very early in the program. The school has never had course-based admissions prerequisites, admitting applicants from any premedical degree program. The MD program is delivered across three campuses in Southern Ontario and is one of two 3-year medical programs in Canada. Students participate in Canada’s national residency matching process.
MCW–Green Bay is a 134-week, calendar-efficient medical education curriculum leading to the MD degree. Students must have suitability for one of the campus missions of primary care, psychiatry, and general surgery. The campus includes a multidirectional digital classroom with robust connectivity to each of the other MCW campuses, active learning, case-based learning, and a local gross human anatomy lab. The campus leverages both distant and local clinical faculty and basic science faculty from local universities. The curriculum includes an emphasis on material relevance, maximized learning, retention and retrieval skills, and an accelerated professional development focused on leadership, community engagement, and consideration of population health topics relevant to clinical practice.
Having enrolled its first class in August 2016, MCW–Central Wisconsin is one of two regional campuses of MCW with a mission to produce a generalist and psychiatric workforce for central and northern Wisconsin. A community-engaged admissions process will select 25 students per year to complete a 134-week, calendar-efficient curriculum, entirely on the Central Wisconsin campus and in surrounding communities. The clinical curriculum will use a longitudinal integrated clerkship (LIC) model rather than specialty-based block rotations. In addition to local MCW and regional university faculty, the campus will make extensive use of multinodal digital classrooms already in use in Green Bay and Milwaukee.
Mercer University School of Medicine
The Memorial University Medical Center Family Medicine Residency teamed up with MUSM to institute the Family Medicine Accelerated Track (FM-ACT). This innovative three-year accelerated medical school curriculum track aims to increase the number of medical students choosing careers in primary care, with a focus on underserved areas and patient-centered care. FM-ACT includes longitudinal clerkship experiences and a conditional acceptance to an MUSM residency program in family or internal medicine.
NYU School of Medicine
The NYU School of Medicine Three-Year Pathway program allows students to tailor their training through the development of individualized pathways, offered by each of the school’s Accreditation Council for Graduate Medical Education–accredited programs. It is the first integrated program in the United States that provides conditional acceptance into any residency program at NYU. One benefit that will be focused on is the ability to track students’ competency and development over seven (or more) years from UME through GME. The program allows students who are confident about their career choice to individualize their training, enter practice earlier, and partake in education and research in the field in which they are most interested.
Penn State College of Medicine
The Family Medicine Accelerated Program at Penn State is one of Penn State College of Medicine’s education reform initiatives, with the goals to build the primary care physician workforce, better align medical training with the health care needs of the nation, and develop a competency-based education that supports individualized learning. This program offers an LIC for the clinical core training where students will follow a panel of patients over a year, creating opportunities to foster meaningful relationships with patients, and links UME–GME goals to facilitate continuity with patients, faculty, and learning environment.
Texas Tech University Health Sciences Center
The Family Medicine Accelerated Track (FMAT) at TTUHSC is a three-year curriculum that leads to the MD degree and links program graduates to family medicine residency in one of TTUHSC’s three programs. The program’s overall goal is to expand the primary care physician workforce by accelerating the pathway, reducing student debt, and increasing the visibility and status of family medicine within the academic health center.
UC Davis School of Medicine
In collaboration with Kaiser Permanente Northern California, the UC Davis School of Medicine’s Accelerated Competency-based Education in Primary Care (ACE-PC) Program is a six-year UME–GME pathway for students committed to primary care careers. ACE-PC students maintain a three-year primary care clinic at Kaiser Permanente. Students gain conditional acceptance into a regional primary care residency program. The program has a diverse cohort of students, many from communities underrepresented in medicine. The program will expand to additional specialties starting with psychiatry in 2017.
University of Louisville School of Medicine
The University of Louisville School of Medicine Rural Medicine Accelerated Track (RMAT) pilot program was created to increase the number of primary care physicians in rural underserved areas of Kentucky. The program’s primary focus is on matching matriculants into family medicine residency programs in rural areas, but students are able to apply to any primary care residency. Students are recruited at admission to medical school but not fully committed to the track until after the second year of medical school. RMAT students complete all classroom and clinical courses required by the four-year curriculum, using break times to complete additional requirements geared to preparing them to serve rural patient communities.
Details of each program are provided in Tables 1, 2, and 3. Table 1 summarizes each program’s start date, specialty focus, mission, financial support, number of students enrolled per year, and number of graduates as of June 2016. In general, the CAMPP member programs can be categorized into two subgroups—those targeted towards primary care or family medicine residencies, and those programs that are not limited to primary care. Moreover, both subgroups include programs that link their medical school accelerated pathway to residency training at their own or related institutions as a UME–GME continuum and those that prepare students to seek residency training elsewhere. All CAMPP member programs share the goal of reducing debt burden for students. For those programs whose mission is to train primary care physicians, an important and related goal is to help address whatever role such debt plays in students’ reluctance to choose primary care careers. McMaster’s mission focuses on developing generalist physician competencies, whereas the mission at NYU School of Medicine centers on individualized training, recognizing that there is a subset of students who are certain about their career choice early on. All programs recognize the importance of selecting mature and motivated students who can handle the rigors and pace of an accelerated program. Besides the McMaster and MCW programs, where all students complete accelerated programs, CAMPP programs are small, representing approximately 1% to 15% of the matriculated class at each school.
Five programs link UME to GME with conditional acceptance into their own residency programs. Like the NYU program, these UME–GME continuum programs target talented students who have made an early career choice and have a strong ability to accelerate and integrate their undergraduate and graduate medical careers in their chosen field. These programs integrate clinical experiences earlier in medical school, through longitudinal clinical experiences, earlier clinical clerkships, or shadowing experiences. The UME–GME continuum model also allows for the introduction and mentoring of students within departments earlier through course work taught by department or residency faculty, shadowing experiences, clinical rotations, and research opportunities available immediately upon acceptance into the accelerated program. Three CAMPP schools are not directly connected to residency programs at matriculation (McMaster, MCW, and Louisville). McMaster’s students have not had difficulty matching into residency programs.12 For the other two programs, it is speculated that residency programs will carefully evaluate a candidate’s suitability for residency selection through the incorporation of competency-based assessment with attention to the medical student achievement of entrustable professional activities and direct skills validation that will provide evidence of student achievement in an accelerated program.
As of 2016, just four CAMPP programs have program graduates. McMaster, which has been awarding three-year MD degrees for decades, produces graduates who obtain residency positions equivalent to four-year graduates of U.S. and Canadian medical schools.12 TTUHSC’s FMAT program has 20 graduates to date who are currently in residency and performing at the same level as their four-year peers, as measured by in-training exams and progress toward milestones.13 These students transitioned easily into residency, perhaps reflecting prior mentoring and familiarity with clinical settings, faculty, and other residents. From each of the first two classes, an FMAT graduate has been chosen as a chief resident. Several graduates have already signed contracts to practice in Texas, meeting a key goal of the accelerated program. Five FM-ACT graduates are in the MUSM family medicine residency. Like the TTUHSC experience, their performance on United States Medical Licensing Examination (USMLE) Step 3 exams and in-training exams has been comparable to that of their four-year peers, and their clinical evaluations are at the top of the class. Two FM-ACT graduates will be chief residents. Louisville has graduated 1 student with performance equivalent to that of her four-year peers. NYU graduated its first cohort of 15 three-year pathway students in May 2016. Their performance did not differ from that of their NYU four-year peers in terms of available measures of learning outcomes including mean medical knowledge exam scores in the basic science curriculum, in the percentage of high honors within the clerkships, in the mean clerkship National Board of Medical Examiners subject examination scores, or in the election to Alpha Omega Alpha honor society.
The financial support varies across CAMPP institutions and includes state support, grant funding, support from affiliation with clinical partners, tuition support, and/or sole institutional funding.
Table 2 summarizes the student selection processes. Most programs accept students at matriculation or during the first year of medical school. Selection criteria are similar to those for four-year programs; for programs that link UME to GME, residency program directors and faculty participate in the admissions process. Evidence of students’ commitment to the school’s focus specialty is a key feature for likely admittance.
Table 3 compares the curriculum and the timing of the USMLE Clinical Knowledge and Clinical Skills exams between the accelerated program and the traditional program at each school. A concern of opponents of three-year pathway programs is that students miss core didactic content; however, analysis of curricular details of accelerated programs has shown that for most programs, the preclinical curriculum is identical to that of four-year students (see Table 2). By participating in rotations that occur over the summer breaks and vacations, or with earlier start dates, students in three-year programs typically lose only 10 to 20 weeks compared with their peers in four-year programs. Another perception posed by critics is the implication that primary care physicians need less medical school education than specialists. The CAMPP schools with a primary care mission were purposeful in their curricular design to ensure that students meet all graduation requirements. Through improvement in curricular efficiency, continuity clinical experiences, and mentorship, key educational components are maintained and enhanced. With data showing that LICs are an efficient model of training where learners are more likely to engage in hands-on learning activities, several programs have added this element.14 Graduates of LICs are more patient centered and have a higher rate of knowledge retention.15 Data on graduates from CAMPP schools thus far support that trainees from accelerated programs are competent physicians with successful careers.
Graduation is governed by requirements at each school. Many of the programs offer defined opt-out options that allow students to return back into the traditional program and graduate after four years.
Key regulatory and licensing issues must be considered in the formation of an accelerated pathway program. The Liaison Committee on Medical Education (LCME) has authority for accreditation of medical education programs leading to the MD degree. The LCME has reviewed several programs with the expectation that accelerated programs observe the existing requirement for medical school curricula to include at least 130 weeks of instruction. While California was one of a few states that required a minimum of four years of medical school to qualify for a medical license, at UC Davis, the University of California Office of the President and key legislators worked with the California Medical Board to develop new legislation that allows students who graduate from accredited medical schools in less than four years to be eligible for licensure. The bill was signed into California law in July 2014.
For CAMPP programs linked to residency, arrangements for participation with the National Residency Matching Program (NRMP) differ. Two programs (TTUHSC and MUSM) use the 2013 NRMP family medicine accelerated track exception to the All In Policy.16 This policy requires programs that participate to fill all of their positions through the Match but grants exceptions for special situations. The remaining three programs that allow conditional acceptance to residency (NYU, UC Davis, Penn State) require students to apply through the NRMP. According to the Match Participation Agreement, institutions can guarantee students that they will be ranked to match, but students can apply to and rank programs outside of the conditional acceptance program.
The Role of CAMPP
The goal of the consortium is to provide networking support and collaboration opportunities for medical schools with accelerated three-year MD programs and to provide guidance to institutions considering the implementation of an accelerated program on the logistical, regulatory, professional development, and competency concerns that must be addressed for successful implementation. CAMPP schools will collaborate with licensing and regulatory agencies and serve as the cornerstone for a national discussion of accelerated pathway programs. The consortium intends to provide information regarding scalable, replicable, and portable models that may be adopted by other medical schools building accelerated programs.
Lessons Learned Thus Far
Four key lessons have emerged from the collective experiences of CAMPP schools. First, students’ and graduates’ performance are similar to that of their four-year MD peers, although the number of students enrolled in these three-year programs is generally small.
Second, a key component of mentoring for accelerated students must include the development of professional identity and certainty of career choice. Best practice includes the design of a program that enables students to have interactions with their residency department early on, whether through formal or informal interactions. Programs should enable early opportunities for a student to shadow, to meet faculty and residents, and to explore research opportunities. Such exposures allow a student to solidify their career choice or decide to transition out of the program or into another specialty if they have a change of heart.
Next, there is a latent interest among many medical students for acceleration as their career plans in medical school become more formed. At NYU School of Medicine, for example, an opt-in option to the three-year pathway was made available for students finishing the first year of the conventional four-year track. In the two years that this option has been available, approximately 15% of each qualifying class has applied, and over 40% have been accepted. Therefore, rising second-year students from the class of 2018 will join those who had matriculated at acceptance to form an accelerated cohort that will approach 15% of the school’s overall class to graduate in 2017.
Finally, programs must also include pathways to transition out of the three-year and into the four-year program (opt-out). Opt-out transitions could be due to student choice or at the request of the institution if the program determines that the student needs additional time for training. At NYU, faculty predicted that 30% of students might change their specialty choice; however, among the 16 three-year pathway students in the initial cohort, only 1 transitioned into the four-year pathway because of a change in specialty, and 1 changed specialty but remained within the program. Among the 48 students who have begun the FMAT program at TTUHSC since 2011, 4 students chose to return to the traditional curriculum, citing the need for more time to choose a specialty or the desire to match outside of TTUHSC, and 4 were counseled back to the four-year program for more academic support. Designing a curriculum where the three-year pathway and four-year pathway are aligned is essential and makes such transitions less complicated.
Emerging medical education reforms designed to meet the needs of society as well as contemporary learners have led to the development of innovative accelerated programs. While only a few medical schools currently have an accelerated pathway program in place, many more are developing or considering one. The CAMPP programs can provide valuable information to other schools considering the development of an accelerated pathway program.