BLOG: Explore opportunity to learn: Path to medical education in India vs. United States

ByJay N. Verma

Fact checked byKristine Houck, MA, ELS

As a senior in high school beginning my journey of higher education, I have started to think critically about the pathway to become an orthopedic surgeon, including the actual cost and opportunity cost with investment in time.

My passion for orthopedics is based on influences from my father, research experience and clinical exposure. I come from a family in which my parents are physicians, but they had different paths to get there. My father was educated in the United States following a conventional approach, while my mother was educated in India, only coming to the United States for residency training.

Application process

According to the Association of American Medical Colleges (AAMC), there are 157 medical schools in the United States, but with more than 60,000 applicants yearly and increasing, less than half of the applicants are accepted. The number of U.S. medical schools has slowly grown, with 29 newly accredited medical schools and 17 osteopathic school opening since 2002.

In the United States, the AAMC predicts a shortage of between 54,100 and 139,000 physicians by 2033, and more than 40% of U.S. physicians will be aged 65 years or older in the next decade. According to AAMC’s report The Complexities of Physician Supply and Demand: Projections From 2018 to 2033, the U.S. population aged 65 years and older is projected to increase by 45.1% by 2033.

With fewer than 35 medical schools established in the past 40 years, the medical education system of the United States is under more pressure than ever to develop a competent workforce. According to Forbes, approximately 25% of practicing physicians in the United States are born on international land, leaving the U.S. medical system heavily reliant on these practitioners. Furthermore, of all the international medical graduates practicing in the United States, 23% have graduated from medical schools in India, according to the National Library of Medicine.

Physician shortage

The medical education system in India has the same physician shortage problem. However, this is rooted in its large population. According to The World Bank, India had 0.9 physicians per 1,000 people in 2019. Furthermore, many physicians educated in India leave the country to practice, which is a problem that does not frequently happen in the United States.

Having a more than 8-year pathway to become a licensed surgeon, markedly reduced cost of education, a significantly larger and younger population, and nearly four times the number of accredited medical schools with a total of 579, according to The Washington Post, India can produce considerably more physicians to keep up with demand.

With the fast growth of physicians becoming certified in associations like the Indian Orthopedic Association and the sheer size of its population, India's future medical care possibilities are limitless. Does the U.S. system need to take notice? Should the U.S. address its limitations, including time, cost and the number of medical students?

Path to a MD

The path to achieving a medical doctor degree in the United States is generally done via a 4-year undergraduate education followed by a 4-year MD program. Residency requirements are a minimum of 3 years, and the path to an orthopedic subspecialty requires 5 to 7 years of postgraduate education. Future orthopedic surgeons will spend, on average, 15 years in post-high school training before beginning independent clinical practice. The average age of surgeons starting to practice is 36.8 years old, compared to India, where one could become a practicing surgeon at 25 years old or even younger in some cases, according to the National Library of Medicine and Business Insider India.

Many physicians trained in India provide care to the U.S. population and have ascended to some of the highest positions in academic medical centers. Is this time for training necessary? Are we producing better physicians or unnecessarily lengthening the time to complete the process? In 2019, the AMA estimated that 43.9% of matriculating medical students took at least a 1- to 2- year gap at some point in the process. The international experience supports the movement of students into medical school more quickly and allows them to focus early on in their chosen subspeciality. Does an orthopedic sports medicine surgeon need to spend 9 months of education in spine surgery or vice versa? Can medical education in the United States continue to innovate in curriculum pedagogy?

Apprenticeship model

An aging population and physician retirements have contributed to a continuing deficit in health care professionals. Furthermore, because residency programs are frequently aligned with large hospital systems or academic centers, orthopedic physicians in-training have a greater focus on inpatient care and trauma. With the site of the patient and surgical care moving rapidly toward an ambulatory system, this dichotomy may reflect physicians being less prepared for the real-world environment.

One solution may be the privatization of postgraduate education. Junior physicians can be employed to work alongside more senior physicians, similar to a physician assistant model. As such, they can bill reduced amounts for their services, offsetting their salary, but provide a valuable service to fill the health care provider gap, all while receiving advanced training. This apprenticeship model is successfully applied in other countries, such as India. Furthermore, this model would allow for a more rapid expansion in the number of positions available for residency training. Many orthopedic fellowships use this system today.

The cost of U.S. medical education is the “elephant in the room.” There is a disparity between the percentage of gross domestic product spent on health care in the U.S. compared with other developed countries. According to Education Data Initiative, the average medical graduate completes his or her education with nearly $250,000 in total student loan debt. Furthermore, there is a substantial opportunity cost as physicians are paid essentially minimum wage during their residency and fellowship, and actual earnings are delayed. This equation is not sustainable in an inflationary time with rising interest rates and downward pressures on physician reimbursement. Surgeons in lower-paying specialties may need help to repay the cost of their education and training. If addressed, the financial barrier to entry into the medical profession will remain manageable and avoid deficits in practitioners in needed specialties.

Relevant questions

As a future student looking to enter the medical education pathway, these are highly relevant questions. Can we shorten the medical education process and maintain quality? Can physicians subspecialize earlier rather than undergoing a general educational process that includes subspecialty areas they may never practice? Could privatization expand the opportunities for medical training, allowing an increase in the number of physicians entering practice and decreasing costs?

For years, the United States has imported physicians from India to fill the internal deficit. Instead, we should learn from its system and update our education process at home? From where I stand, it is time for a change.