The Drawn Out Medical Degree: The New York Times

Viewing a Nuclear Explosion: American Science at It's Peak

The August 1 New York Times carried an article "Drawn Out Medical Degree," in which it reported about the move toward reducing the traditional four years of medical school to three. 

The Phantom has often said the American medical profession has been ineluctably moving toward where the British medical system was in 1970, and this is another instance.

Any physician talking about medical education tends to see the system from a worm's eye view. Ask an American doctor what we ought to be looking for in a future doctor and he will describe his own attributes. So, for years, doctors have endorsed the absurd "qualification" of being good at calculus, because they were selected for being good at calculus and those who weren't were eliminated, so there is nobody left in the professional corridors of power to raise the manifestly true point that being good at calculus is in no way predictive of being good at medicine, or surgery, or that calculus is even helpful in a medical career. Ditto for organic chemistry, physics,  physical chemistry and comparative anatomy.

The fact is, the American system of educating doctors went from the pre Flexner commercial diploma factory to the university based diploma mill which created a very high bar, and attracted "high achievers" but likely did not find the best doctors.

If it were up to the Phantom, he would start identifying  students out of high school, as they arrive at college--and they should go to college--and provide a pre medical school curriculum through college which allowed the students to judge whether or not they really want to be doctors and would provide a tracking system to identify who might really become good doctors in a meaningful way. This system would separate the students seeking to do "clinical medicine" from those doing research while allowing for overlap and what is called "translational medicine."

Currently, every student is prepared to be all things, a researcher in microbiology, anatomy, pathology, biochemistry, etc and the process is discouraging and counter productive. 

A better system would allow for some acceleration of the training process, for those who could learn all the biochemistry they needed to know in 6 weeks rather than a full year. This is called "competence based" training, by which they mean, if you can learn anatomy enough to pass the exam in one semester, you can hurry through medical school in a few years. This should work well for the "preclinical" sciences, which are mostly forgotten by fourth year anyway, but it would not work for clinical training, which simply requires exposure to patients, the widest variety of diseases with enough repetition to make sure physicians actually graduate knowing what they are doing. Clinical competence cannot be acquired quickly, and no test devised by man has ever been able to test for it. You cannot know whether an airplane pilot is competent to fly by giving him a number two pencil and having him do a multiple choice test. There is no substitute for flying hours. There are flight simulators in aviation and there are simulator dummies in medicine, but there is no way to assess the complexity of decisions necessary in either which is easy. 

Surgeons who complete their residencies nowadays cannot go to the operating room without an older surgeon assisting them, because Libby Zion laws restricted the number of hours they could work, the number of cases they could do and so they "finish" not being adequately trained, because surgery, like flying simply requires a certain number of hours of practice. 


The new Phantom system would eliminate the high price institutions (Harvard, Columbia, Penn, Cornell) as "elite" institutions which can price their "product" exorbitantly, and replace them with government sponsored students. Medical education ought to be free and tied to "pay back" in service from the students.  Harvard could still educate tomorrow's doctors, but it would be paid no more than U. Mass for that privilege. 

And it would eliminate the burgeoning ranks of "medical schools" now in full flower and pare back to the number the nation really needs, not the number entrepreneurs can sell.

But most of all, it would focus on selection, finding the right people for the right jobs. It would do this scientifically, relentlessly and we'd all be better off for it.

It would mean, among other things, part time physicians would likely be phased out. Why train a physician at government expense, who, predictably, would serve only 10 or 15 years, when you could train one who would, on an actuarial basis, serve 20 or 30 years?  It's not cost effective to train doctors who will not serve. Currently, high  edebt drives doctors to keep practicing, at least enough to pay off their debts. But for those women, who are married to high earners, that incentive is often not enough, as increasing numbers of women doctors are saying, "My kids come first. We can afford for me to work only 2 days a week."

So, in the case of public health, the Phantom is all for abandoning the unplanned, "free market" system we say we have, for a government run system of training. 

Better bang for the buck.