Slow and steady wins the (medical school) race

Issue: October 2014

ByWilliam T. Gerson, MD

I’m in a hurry to get things done

Oh I rush and rush until life’s no fun

All I really gotta do is live and die

But I’m in a hurry and don’t know why.

— “I’m In A Hurry (And Don’t Know Why),” Alabama, Roger Murrah, Randy VanWarmer, 1992

School and the work whistle blow.

Everybody had to rush, rush, rush around.

I remember thinking this just can’t be right.

Got to be a better way to live your life.

Slow like a soft Southern breeze.

—“Rush Around,” Edie Brickell, 2003

Miracle Max: You rush a miracle man, you get rotten miracles.

—“The Princess Bride,” 1987.

One advantage of summer vacation is that you can catch up on reading, even having time to fully read the Sunday New York Times (the real thing, not the online variety) — particularly if it is 40 degrees and raining in August in the Adirondacks. I was especially caught by surprise by an article on the making of 3-year medical schools. My first impression was really, what is the rush? Rapidly followed by the cynic/curmudgeon within — unless the goal is to produce a generic physician. And maybe it is.

William T. Gerson

Of course, along with most everything involving education, 3 years of medical school is not really new. When I was in school, several universities had BA/MD programs that shortened the combined time from the customary 8 years. There were likely several different reasons to adopt such programs: attracting applicants to one’s institution, acknowledgement of a significant overlap between undergraduate science curricula and that of the basic science portion of medical education, and even attempts to free premedical undergraduates from the real or perceived narrowness of their education plans by guaranteeing medical school acceptance, thus allowing humanistic courses to enrich one’s undergraduate life.

Discovering a definitive purpose

I am certain that a 3-year curriculum is viable and well vetted by the medical education bureaucracy that likes nothing better than another project. Already the modern 4-year curriculum has almost 6 months (if not more) off for questionable activities — time for studying for multiple national board exams, residency interviews, community projects, tangible research products and, yes, even vacation. Is the goal purely time based? A hurry to get things done? If so, I wish the rush would sip a Southern breeze.

Perhaps the movement is a welcome indirect attack on the too-much-information-to-learn fallacy. While I agree on the fact of an explosion of knowledge, I have never accepted the line of thought that what we learn in medical school becomes less relevant with time, unless what we are learning is not worth learning in the first place. Aren’t we learning how to think? True paradigm shifts in medical science certainly take place, but they are uncommon. What is needed is the awareness and aptitude to integrate ongoing new information into practice. Facts change, not wisdom.

Is medical school a professional school or a trade school? If the goal is the production of more clinicians in less time, we already do this — we call them NPs or PAs. We can also create primary care quickly — we call it Wal-Mart primary care, or even more simply, allow chiropractors and naturopaths to be considered fully accredited primary care doctors. Surgical skills, endoscopies, ultrasounds can follow the path of nurse anesthetists. What do we want to become as physicians?

If we are in a rush, let’s have at it. Why nibble at the edges of a transformative revolution? Let’s feast on graduate medical education as a whole — it’s not just medical school, why are we continuing with a model of residency and fellowship that has not demonstratively changed over decades despite the current misguided fixation on hour limits and increased needs for both sub-subspecialists and primary care?

A re-imagined model

If medical school in 3 years is the new normal, I say let’s re-imagine it as taxpayer-financed, competency-based, with no national exams and no internship interviews, just a smooth transition. When the individual is ready, he or she can matriculate to a medical school controlled learning environment that mimics a current internship. Receipt of MD after completing 3 years, with the cost of the “internship” year to be paid by the individual if not primary care, free for primary care. Subsequent years of primary-care residencies salaried as they are now by federal dollars and hospital dollars, nonprimary care residencies paid for by individuals. Billing as a physician (if billing still exists) — to begin after MD plus 1 year. Longer residencies as more humanely focused time restrictions are implemented, thus requiring more years. However, long fellowships give way to shorter training with an apprentice level (able to bill in all areas of specialty for which training is over, needing supervision in the narrower area of subspecialization) to follow for those areas requiring longer training. No longer will fellowship end in the early to mid-30s, even for those who enter medical training in their early 20s. Medical schools and hospitals as units of ACOs take full responsibility for quality of care.

Such a plan would have the additional benefit of being pregnancy and family-time friendly from medical school through fellowship. Rarely will students or residents change their university affiliation. Abandoning any semblance of the old “house-officer” model, shift care becomes the norm with increased limits on consecutive days of work. House staff and their families benefit, and hospital administrators can finally get their 24-hour hospital functioning, as no longer would there be any difference between day or night, weekend or weekday. Plenty of clinicians on duty.

Very efficient, perhaps miraculous. But Miracle Max might be correct, rush things and we may get rotten miracles for us all.

References:

Grady D. The drawn-out degree. The New York Times. Aug. 3, 2014:ED21.

For more information:

William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.

Disclosure: Gerson reports no relevant financial disclosures.