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To Cut the Costs of Medical Education, Trim Training

Rachel Eastwood Jason Sanders

It is no secret that medical training is long. Whether at cocktail parties or family reunions, the student doctor stays on alert for the well-meaning if often-repeated question: “How much longer do you have left?” Yet no matter how many times I rehearse a reply, my audience invariably begins to lose comprehension, with glazed eyes and fretted brow. “Hmmm,” the slow pause ensues until, “so when do you actually become a doctor?”

Implementation of a new (four-year-plus) curriculum already is in full gear at HMS, so perhaps this column won’t launch blue-sky committees anytime soon. On the other hand, opportunity knocks for the first entrepreneur since the 1970s who can establish a three-year American medical school pathway.

But before we dive into the thick of medical school, let us retrace our steps all the way back to high school.

Time Waster

Opinions abound on secondary education, and fortunately innovation continues from Teach for America to the Knowledge Is Power Program (KIPP) to local education foundations. A major challenge from the medical school perspective is to inject rigor into preparation for college so that once students enter, they are on a better footing, particularly in the sciences. At the college level, premed requirements of the Association of American Medical Colleges (AAMC) take about one and a half years. The expectation is that this period allows adequate preparation and that all medical school applicants take the standardized MCAT. But concern remains among medical educators that science education is not equal across campuses, so much time is lost during the first year of medical school getting everyone up to speed.

Potential solutions include:
• Formalizing curriculum accountability between medical and undergraduate faculties at institutions that have both schools;
• Accrediting premedical programs;
• Improving MCAT psychometrics.

Making the Cut

During the early 1970s nearly one quarter of American medical schools established flexible three-year programs, but these fell quickly out of favor by the end of the decade. Yet in 1988, Robert Ebert, who was the HMS dean from 1965 to 1977, and Eli Ginzberg, Columbia economist and presidential adviser, raised a similar call to action in a Health Affairs article. Though AAMC reports in the early 1990s acknowledged the cogency of their argument for increasing flexibility in medical education, the four-year pedagogy grew more ingrained, particularly in the context of flourishing basic science departments.

Today, medical debt headlines as a priority for the AAMC, American Medical Association, and nearly every student group who can post a blog, but the hand-wringing tends to push aside solutions from other sectors: cutting costs (i.e., reducing training length) and growing top-line revenue (i.e., increasing housestaff salaries).

Enter E. Ray Dorsey et al.’s 2006 Academic Medicine study, once again providing a compelling economic perspective: “Decreasing the duration of medical education offers the greatest potential for reducing the financial burden of medical education.”

The findings include:
• One year less of medical school yielded a net present value (NPV) benefit ranging from $160,000 to $230,000 (using a 6 percent discount rate in the calculation);
• Increasing residency compensation to that of a first-year physician assistant yielded an NPV benefit ranging from $60,000 to $100,000;
• Reducing medical school tuition by 25 percent had the smallest financial impact—$30,000.

Paradigm Shift

Economics is important, but would a three-year MD play in Peoria?

To allay concerns about shaking up the four-year precedent, I would cite the 34 BS/MD programs that typically last six years, as well as the shorter total duration of most foreign medical schools (usually entered as an undergraduate).

As for logistics, the standard four-year track could take a haircut either at the front or the back. Time and energy invested in premedical courses (from general chemistry to molecular biology to statistics) should tee up matriculants to tackle the exciting science of clinical medicine. Even allowing room for a short refresher course, this classroom-based work could be completed in one year, enabling future physicians to start laying hands on patients—the soul of a healer’s training—in their second year. And on the back end, the predominance of electives in the fourth year could be combined rather easily with internship to recreate a more transitional year.

Change is unlikely under the auspices of committees and task forces. The ideas are before us, and as in so many areas of clinical services, we need leaders who will start pilot programs. For a profession grounded in the scientific method, it is surprising that providers are so reluctant to experiment with entirely different training methods. Great strides have been made since the Flexner report, but standardization need not be our only theme.

—Jason Sanders is a fifth-year medical student at HMS.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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Copyright 2007 by the President and Fellows of Harvard College