Monday, December 18, 2017
Opinion

Do doctors really need 14 years of training?

We need more doctors. On a global scale, the shortage is staggering: The World Health Organization says we need 15 percent more doctors. In the United States, the American Association of Medical Colleges estimates the current deficit at almost 60,000 and forecasts a worrisome 130,600-doctor shortfall by 2025. There's one simple solution: We have to consider ways to manufacture doctors faster and cheaper.

An American physician spends an average of 14 years training for the job: four years of college, four years of medical school, and residencies and fellowships that last between three and eight years. This medical education system is the result of a reform movement that began in the late 19th century and was largely finished more than 100 years ago.

The circumstances were vastly different at that time. Until the Civil War, private, for-profit medical schools with virtually no admissions requirements subjected farm boys to two four-month sessions of lectures and sent them off to treat the sick. Abraham Flexner, the education reformer who wrote an influential report on medical education in 1910, put a fine point on the problem: "There has been an enormous over-production of uneducated and ill trained medical practitioners," he wrote. "Taking the United States as a whole, physicians are four or five times as numerous in proportion to population as in older countries like Germany."

In other words, our current medical education system was originally designed to reduce the total number of people entering the profession. The academic medical schools that sprang up around the country made college education a prerequisite. Medical school expanded from eight months to three years and solidified at four years in the 1890s. Postgraduate training programs were implemented, beginning with a one-year internship. These were brilliant reforms at the time.

Over the past century, there have been additions to, but few subtractions from, the training process. Residency and fellowship programs became longer and longer. The path to some specialties is now almost comically arduous.

One solution is to simply lop off a few years from the process. Writing in the Journal of the American Medical Association in 2012, bioethicist Ezekiel Emanuel and economist Victor Fuchs recommended shortening each stage by about 30 percent. Four years of premedical training shouldn't be a requirement for those who don't want it or can't afford it, they argued. The fourth year of medical school is largely a breeze, and a few progressive medical schools are now offering three-year programs to reflect that reality.

As for postgraduate training, Emanuel and Fuchs attacked the increasingly common requirement that residents and fellows complete laboratory or clinical research projects. They don't buy the popular ideal that every doctor must be a "physician-scientist." Referring specifically to surgeons, they wrote, "The most important factor in becoming a competent surgeon is high volume — performing specific procedures many times over. A research year does not add to surgical volume and skills building."

Another solution, perhaps more elegant, is the outcomes movement. Medical schools and residency programs have traditionally relied on the "tea steeping" method: They expose students to information for a prescribed amount of time, and assume they're ready at the end of it.

Years can be added if a student demonstrates gross incompetence in exams, but there's no opportunity for exceptional students to accelerate the process. Offering that chance makes educators uncomfortable — both because it relies heavily on imperfect examinations and because it partially undermines the traditional process — but it's time to experiment.

Doctors have very rarely examined their own training. Emanuel and Fuchs could find just one study comparing the competence of physicians from the traditional four-plus-four medical education system with that of doctors from shortened programs.

It's time for doctors to turn the microscopes on themselves and their own training, and accept that the system that produced them may be imperfect. It's nothing against you, Doctor, it's just a scientific inquiry.

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