Rethinking the duration of medical school: Enough is enough! Or is it?

Myron Yaster MD, Alan Jay Schwartz, MD MSEd, Justin L. Lockman MD MSEd, Aditee Ambardekar MD MSEd

Rethinking the duration of medical school: Enough is enough! Or is it?

Myron Yaster MD, Alan Jay Schwartz, MD MSEd, Justin L. Lockman MD MSEd, Aditee Ambardekar MD MSEd

In the U.S. model of medical education, students go to an undergraduate college/university for 4 years (usually a liberal arts education) and at graduation receive either a Bachelor of Arts or Bachelor of Science degree (usually BA or BS). During their undergraduate education, students apply to medical school and, if accepted, go on to receive a Medical Degree (MD or DO) after 4 additional years. This is then followed by graduate medical education (residency and possibly fellowship(s)) that can vary in duration from 3-12 total years depending on specialty. Is this duration of training necessary?

Because of work force shortages and ever-increasing medical school debt, some medical schools are rethinking the duration of medical education and have developed an accelerated 3-year pathway. Compared to traditional 4-year medical students, do these accelerated program students match up with respect to satisfaction with education quality, the learning environment, residency readiness, burnout, debt, and career plans? Will medical students educated in accelerated programs be accepted into residency programs? In today’s PAAD, Leong et al.¹ investigate and provide some answers. Myron Yaster MD

Original article

Leong SL, Gillespie C, Jones B, Fancher T, Coe CL, Dodson L, Hunsaker M, Thompson BM, Dempsey A, Pallay R, Crump W, Cangiarella J. Accelerated 3-Year MD Pathway Programs: Graduates' Perspectives on Education Quality, the Learning Environment, Residency Readiness, Debt, Burnout, and Career Plans. Acad Med. 2022 Feb 1;97(2):254-261. doi: 10.1097/ACM.0000000000004332. PMID: 34380931; PMCID: PMC8781222.

Does medical school really need to be 4 years? How did we arrive at 4 years?

In 1910, the Carnegie Foundation for the Advancement of Teaching published the so-called Flexner Report which transformed North American medical education.² The four year medical degree with a basis in science and standardization of curricula was its crowning achievement. In 2010, the same Carnegie Foundation issued a new report calling for reform.^2,3 Based on this 2010 report, several U.S. medical schools developed accelerated medical school programs to allow students to obtain their medical degree in 3 years instead of 4.⁴ In today’s PAAD, Leong et al.¹ “used customized Association of American Medical Colleges (AAMC) Medical School Graduation Questionnaire (GQ) reports to compare the perception of accelerated and traditional students, with respect to the following aspects of the student experience: satisfaction with the quality of their education, the learning environment, readiness for residency, burnout, debt, and career plans.” It should be noted that the GQ is a survey of medical students in their final year of school, before many of the realities and challenges of residency and life after medical school begin.

What did Leong et al find? Not surprisingly, students in accelerated programs graduated medical school faster, with less debt, and without negatively impacting the trainees’ perception of burnout, education quality, or preparedness for residency.¹ The onerous impact of medical school debt (now exceeding an average of $250,000) on graduating physicians often influences and almost compels graduates into more lucrative and higher paying medical professions like anesthesiology – and for those interested in academics, sometimes away from academia as well!

Did the lack of a 4^th year affect students’ knowledge or abilities to perform in post graduate training and beyond? Importantly, are medical trainees the optimal group to be asking about their own abilities and knowledge? […We think not!] The survey-based methodology is a limitation of this work; moreover, the survey participants have limited knowledge and experience outside of their medical school experience.

As a side note, 35 years ago an investigation of a separate accelerated program, the McMaster MD Program, compared graduates of traditional 4-year US and Canadian programs to a novel 3-year Canadian program, with accelerated MD graduates finding they performed similarly on standardized national examinations, in the competition for residency positions, and during subsequent graduate medical training.⁵ But is that still true today?

Leong et al added that the current group of “accelerated MD graduates reported being more likely to enter family medicine and to care for medically underserved populations.”¹ We don’t know how to interpret this finding – is it selection bias at the start (financial pressures, primary care interest, or other)? Is there something about the 3-year pathway that would make people more prepared for or interested in primary care? It would be worthwhile to explore these questions further.

An interesting finding in this study is that many of these accelerated medical school programs fast tracked their students into their school’s own residency programs. This is important because as Leong et al. point out, “In a recent survey, only 34% of residency program directors said they would accept accelerated students from schools outside of their own institution.”⁶ Finally, accelerated students entering into an institution’s own residency programs allows students to become “integrated into a specific department and intended specialty earlier than their nonaccelerated counterparts, and the close mentorship, personal engagement, and autonomy that may result from this earlier integration may help mitigate burnout.”¹ Students applying and being accepted into a residency program early in the process is another cost saving benefit – we know that trainees spend thousands of dollars interviewing.

Multiple questions remain, and we hope future work will help answer them. For example:

- Are accelerated graduates as prepared on a psychosocial basis?

- Have residency directors been able to document that accelerated graduates are equivalent?

- Do patients and/or families perceive that accelerated graduates are as mature and display evidence of sufficient life experience?

- Are there implications for state licensure or board certification?

- Do future employers perceive any differences in training and experience?

- Should accelerated programs be mandated to combine training into longer medical school-residency programs?

- Is there reason to create enhanced prerequisites for accelerated programs?

- Does the medical community at large need to shift mindset and accept that 3 years (without enhanced prerequisites or combined pathways) is enough for any medical student? (This is clearly not yet the case as noted in the residency program director survey above).

What do you think? Looking back at your own education, was there an advantage in the 4^th year? As a medical student advisor and residency program director (AA), I have seen a trend in medical schools towards picking a specialty earlier in one’s medical school career, even before exposure to many fields. Does this favor a 3-year curriculum over a 4-year curriculum? Are we doing right by our trainees? I (MY) know that it was crucial in my own career journey. The 4^th year allowed me to sample many different specialties including anesthesiology. I’m certain that if I didn’t have this ability, I would never have discovered anesthesiology, and my career would have had a completely different arc. I (AJS) believe that the 4^th year of undergraduate medical education enabled me to learn a broad array of medical practice information and techniques. With this 4^th year added education, when I became an anesthesiology resident my fund of knowledge and skills were a broader and more in-depth foundation to be a “Doctor”. Perhaps as importantly, we believe that just as a liberal arts education benefits all undergraduate students regardless of career plans, a broad medical education is beneficial for all physicians regardless of future path. I (JLL) for one think this is one of the fundamental differences between medical education and vocational training. After all, we know it doesn’t take 12 years after high school just to learn to place a breathing tube in the right place!

Send your thoughts and comments to Myron at myasterster@gmail.com who will post in a Friday Reader Response.

References

1. Leong SL, Gillespie C, Jones B, et al. Accelerated 3-Year MD Pathway Programs: Graduates’ Perspectives on Education Quality, the Learning Environment, Residency Readiness, Debt, Burnout, and Career Plans. Academic Medicine 2022;97(2):254-261. DOI: 10.1097/acm.0000000000004332.

2. Irby DM, Cooke M, O'Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med 2010;85(2):220-7. (In eng). DOI: 10.1097/ACM.0b013e3181c88449.

3. Emanuel EJ, Fuchs VR. Shortening medical training by 30%. Jama 2012;307(11):1143-4. (In eng). DOI: 10.1001/jama.2012.292.

4. Cangiarella J, Fancher T, Jones B, et al. Three-Year MD Programs: Perspectives From the Consortium of Accelerated Medical Pathway Programs (CAMPP). Acad Med 2017;92(4):483-490. (In eng). DOI: 10.1097/acm.0000000000001465.

5. Neufeld VR, Woodward CA, MacLeod SM. The McMaster M.D. program: a case study of renewal in medical education. Acad Med 1989;64(8):423-32. (In eng). DOI: 10.1097/00001888-198908000-00001.

6. Cangiarella J, Gillespie C, Shea JA, Morrison G, Abramson SB. Accelerating medical education: a survey of deans and program directors. Med Educ Online 2016;21:31794. (In eng). DOI: 10.3402/meo.v21.31794.