Many facets to this issue and the points you raise. Most everyone involved (government at every level, payers, employers, med schools, physicians and patients see the reality: too much being spent on healthcare, very difficult to see a primary care doc and all manner of medical tasks being offloaded to lesser trained professionals for the one reason we all know.So what's not to like about making med school quicker, and therefore cheaper, and increasing throughput.
The issue is that the health care system writ large that has created these problems need sto be changed on a fundamental level, or the outcome - the types of physicians in the specialties they choose, the priorities they choose as they proceed in to their adult lives - won't meaningfully change.
(Disclaimer: I retired from 35 years in primary care last year.)
Egads, no... We're already talking about replacing doctors with AI and now we want doctors Less qualified? Plus, we already have remote everything, likely a chunk of the present education length, and now we want Less education? Nope not me.
Beautifully stated. I was trained classically with the only wasted time "scut work," that actually wasn't that bad because it helped me find veins and it helped me quickly tell what was good for the patient. And I suppose it gave a little foretaste of our now much worse medical system.
Aside from the balderdash of woke and DEI requirements the worst criticism of contemporary medical education is that for the past ~30 years everything has been "teach to the test." I can count on 2 hands the number of students and trainees who could think. And this is not the fault of the students but of our leaders in education. Yes, our colleagues at ACGME, the deans, etc. They have harmed American healthcare, American patients, and American physicians. Too bad we can't vote them out.
I especially agree that doctors need to be pushed into critical / analytical thinking, especially regarding the analysis of clinical trials results. Too many simply focus on reading brief summaries that are highly biased and generally published by Big Pharma.
There is no way to fight AI in medicine, so training should include how to effectively and appropriately use AI in their medical practices, and how to double check the accuracy and reliability of their AI tools.
As long as you have doctors practicing medicine according to payment schedules, you will have mediocre care-at best.
The idea of going into medicine to make money has been poisoning the pool long before modern medicine took over. That has to be dealt with. Because the predominant desire to get rich cannot coexist with ethical principles.
If you cannot instill ethics in premed, no amount of medical training will be enough
Coming from a primary care angle thank for your opening paragraph. Absolutely. However I think it would help to be specific about "clinician" or "doctor". I tend to use "clinician" as any patient-facing professional? What is it doctors specifically need and what do all clinicians need? The more all stakeholders (including politicians and political advisers) have the same skills (particularly soft skills like shared decision making and risk communication) and same vocabulary about critical appraisal and value-based healthcare, the better. Otherwise how can they tackle today's knotty problems? High value care often requires teamwork and so does addressing low value care (hand-offs, changes in prescribing all done by "someone else"). Then of course the question is what can only one professional group do, compared to another.... Oh, and could there be mandatory elements like nicotine cessation and death certification.... globally these are rarely taught. Don't know the details of US.
Soooo…going outside the box a bit here. Eliminate the 4th clinical year and mandate two years of general medical practice in a public health setting for EVERY medical school graduate, in exchange for significant financial subsidy of their education. Several problems solved: school debt eased, primary care supported (and some docs may find they like it !), deeper appreciation for general practice demands by specialists of the future, less “ask your primary MD about your constipation” from specialists, etc. And if would-be physicians don’t want to do their share to support public health, well maybe they shouldn’t be physicians at all.
For Those Who Already Know: A Case for the 3-Year Medical Curriculum
I may have a unique perspective in this debate: I was the first graduate of LECOM's accelerated 3-year program, and I went into family medicine.
I didn't walk into medical school at 22 still becoming someone. I had a BS in bioengineering, an MSPH in public health, six years of marriage, two kids, and 27 years of life when I started. I hadn't gotten in right away — and what I did instead was grow. By the time I sat in that first lecture, I knew exactly what I was there for.
That changes everything about how you learn.
While my classmates took the first summer off, I kept working. When they returned in the fall, I was ahead. By February of second year, I'd finished the coursework most students complete in the spring. The whole time, I was shadowing a local family physician one day a month — not just observing, but building clinical identity in parallel with my education. I was coupling textbook medicine with real patients before I was ever credentialed to practice. My peers didn't see their first real clinicals until third year. My first full clinical rotation after Step 1, I was presenting differentials to attendings and running. That mentorship didn't fill a gap the curriculum left — it accelerated formation that was already underway.
I graduated at 30, matched into an excellent family medicine residency, and flourished. My program director told me I was one of the best bets he ever made.
The critics of shortened curricula assume that less time means less formation. But formation isn't a function of calendar years — it's a function of readiness. I didn't need four to six extra rotations auditioning at prestigious hospitals. I didn't need three neurosurgery rotations to confirm what I already knew. I needed to get out there and do the work I came to do.
Consider the inconsistency: we already accept that BS/MD early acceptance programs — which compress undergraduate education into two or three years — can produce excellent physicians. If we trust that premise at the college level, why does the logic suddenly fail when applied to medical school itself? It doesn't. The variable was never the calendar. It was always the student.
The financial reality matters too, and we don't talk about it honestly enough. My alternative would have cost $400,000 — debt I'd likely still be carrying twelve years later. LECOM, one of the lowest-cost private medical schools in the country, cost me $225,000, and that included portions of my prior degrees. I paid it off in six months after residency, between my signing bonus and moonlighting in my final year. That's not a footnote. That's the difference between a physician who practices where they're needed and one who chases income to service debt.
In an era when NPs and PAs are being granted expanding scope of practice, the argument for physician training shouldn't hinge on duration — it should rest on depth, rigor, and formation. Medical education, even compressed, produces better clinicians. But we'd do well to stop pretending that adding time automatically adds quality. We all know colleagues who coasted through four years and arrived at residency half-formed. The problem was never the curriculum length. It was that we're not honest enough about who belongs in the fast lane and who needs more runway.
The 3-year path isn't for everyone. One of my classmates didn't finish residency. The track is demanding and unforgiving, and it will expose every gap in your readiness. For the student still finding themselves, four years isn't wasted — it's necessary.
But LECOM's program has now been running and strengthening for over fifteen years. Programs that don't work get eliminated. This one grew. That's not sentiment — that's a track record.
Primary care has a workforce crisis, and we keep debating the wrong variable. The real question isn't how long medical school should take. It's how we identify and cultivate the people who are already becoming physicians before they ever apply — the ones whose life experience, maturity, and clarity of purpose have done the formation work that four years of curriculum tries to accomplish. We should be building pipelines for those people, not making them wait.
I was lucky. I had my life in order. I knew who I was and where I was going. That readiness was the real accelerant — not the shortened calendar. The 3-year curriculum didn't make me a physician. It gave someone who was already becoming one the chance to get there.
For those students, it's not a shortcut. It's the right road.
"We should be building pipelines for those people, not making them wait."
Couldn't agree more Dr. Keith. I mentioned similar thoughts in my comment below, but not as eloquently as you. The financial reality really looms large, especially with caps on loans, folks who are "nontraditional" older premeds with families as well as from mid/lower SES backgrounds.
This is so weird and coincidental. I was doing a short video about the problem in Indian medical education, where students no longer go to the wards, using The Pitt as a counter example, when I read your post and quickly incorporated a US Viewpoint.
You could shorten the amount of time needed for medical training by adopting a more European model - direct admission to medical school as an undergrad with a a 6-7 year combined program that results in an MD - eliminate summers off ( real doctors don't have summers off anyway ) , substitute regular 2 week vacation blocks and start clinical rotations after year 1 with gradual increase in responsibility. For those who drop out after 4 years an undergraduate degree could be given. This would allow for initiation of relevant anatomy, physiology and critical thinking and math skills at a much earlier time , and eliminate time spent in undergraduate elective studies that may enhance our lives as humans, but aren't particularly relevant to our lives as physicians. We are all smart enough to engage in art history , music and literature on the side if we wish . For those who don't wish, well they weren't benefiting much from enforced undergraduate electives anyway. This would also eliminate a lot of wasted summers pursuing unpaid internships, volunteer gigs, boring research studies all done to try to impress medical school admission committees in a desperate lottery to try to get into medical school . It would also allow less wealthy students to pursue medicine as they would not be forced to spend unpaid summers accumulating brownie points.
I would also propose that residency training and specialty designations should be completely overhauled and changed from " organ system ownership " to a more inpatient /hospital/critical care focused residency vs outpatient medicine . My field of OBGYN is especially in need of this - we can no longer be all things to all women over their entire life span. We need skilled obstetricians who can do deliveries , obstetrical surgeries , deal with medical disease and illness in pregnancy and function as hospitalists and community maternal fetal medicine physicians , leaving MFM fellowships to those few who wish to pursue academic and research carreers. GYN surgery should be it's own thing and oncologic gyn surgery should be part of that specialty , with true GYN Onc fellowship again limited to those wishing to pursue research careers. Those who want to care for women in an office setting could pursue one year of hospital training which includes minor office procedure training /surgery ( hysteroscopy, biopsies, colposcopy etc ) and then should focus on primary care for women with actual expertise in areas poorly covered in current training- HTN, DM, obesity, CV prevention, psych.
It doesn't matter much if they are late teens or early twenties. Everyone (almost) in India is in their teens when they start medical school. Perhaps it's a call to strengthen high school education so it provides the liberal arts foundation that kids are getting in college.
I think medical school education should be shorter, but I think the way to do it would be to offer more combined undergrad/medical school programs. These programs could be a total of five or six years. Undergraduate education could still be relatively broad, but with more of a focus toward medical adjacent topics, even in the humanities, philosophy, and ethics. Science and math classes could also be tailored and include statistical methods instead of super advanced calculus. And work and internship opportunities that many undergraduate participate in could be offered in medical settings to help students begin to have a sense of where they might want to specialize. But I also agree with you that the current approach to medical school education needs some revision and rethinking.
I am not sure if I understood. What do you mean by "Students would then concentrate on learning to evaluate medical evidence and master critical appraisal. Prioritizing these skills would steer people from reasoning based on pathophysiology to reasoning based on evidence. " ? I think that Medicine need much more physiopatologic reasoning. Black-box epidemiologic studies should not be regarded as producing medical evidence. To me, medical evidence requires physiopatologic reasoning, or it is not Medicine. It could be practiced by everyone.
I'll push back from the other end: the USA needs to replace its 8-year system of college + medical school with the European system, in which medical education begins immediately after high school and people complete their basic training in 5-6 years. Too much of the typical U.S. undergraduate curriculum is irrelevant time-wasting fluff for students capable of becoming good physicians.
I graduated from asix-year curriculum structured around three years of basic sciences followed bythree years of clinical training, including hospital and ambulatory rotationsin Internal Medicine, Pediatrics, Obstetrics and Gynecology, and Surgery, withradiology, pathology, diagnostic reasoning, and therapeutics taughttransversally throughout the program. For decades, many have argued that evensix years are insufficient to “master” a profession whose body of knowledgegrows exponentially.
Yet paradoxically, that very curriculum often makes italmost impossible to understand the human being in his or her full dimension —or, more precisely, in every dimension except the humanistic one. Philosophy,ethics, sociology, anthropology, demography, history, geography, culture, andthe humanities in general are frequently treated as secondary distractionswithin the illusion of “saving lives,” or at best as ornamental subjects thatinstitutions themselves rarely embody in practice. Incidentally, why areschools of Medicine, Nursing, or Dentistry almost never housed within Facultiesof Human Sciences? Perhaps, then, thereal question is not whether medical school should last longer or shorter, butwhether we have correctly defined the ethical, anthropological, and epistemologicalpurposes of Medicine in the 21st century.
The debate over theduration of medical education seems secondary when compared to a much deeperproblem: we continue to train physicians within an epistemological frameworkinherited from the Flexnerian model of more than a century ago. A model that,while legitimately attempting to make Medicine scientific, ultimatelyconsolidated a fragmented view of the human being, reducing the person primarilyto a biological entity and reinforcing the Cartesian split between body andmind.Within this paradigm, Medicine progressively oriented itself toward thesymptomatic and diseased individual, treated in increasingly complex,expensive, and technology-driven hospitals by specialists and subspecialistscreated according to the demands of the healthcare market. As a result, theprofession became centered on the late containment of disease rather than onthe deep understanding of its causes and determinants.Paradoxically, much of Western “health care” functions more accuratelyas a “disease care business.” Genuine health promotion and profound diseaseprevention remain marginal because addressing the structural causes of illnesswould reduce the need for much of the interventionist industry that sustainsthe current system.
Premature specialization has significantly contributed to thisphenomenon. The four major specialties consolidated around Johns Hopkinscrystallized a model in which human problems became progressively divided intoorgans, systems, and procedures. We now even speak of training “generalistspecialists,” an expression that itself reveals a conceptual contradiction.Borrowing freely from the spirit of David Epstein’s The Range, one could say: “If you want a problem to grow,persist, and become insoluble, specialize exclusively in that problem.”
Therefore, before discussing whether medical school should last three,four, or six years, medical schools should first ask what kind of professionalcontemporary societies truly need. It is profoundly different to train expertsin the late management of disease than to train health professionals capable ofunderstanding, practicing, and teaching the conditions that promote theaccumulation of health.
Perhaps the early university years should focus less on memorizingever-expanding volumes of biomedical information and more on teaching studentshow to live healthfully, critically evaluate scientific evidence, understandthe determinants of health, think deeply, and cultivate a strong humanisticfoundation. A physician incapable of applying healthy principles to his or herown life will struggle to inspire health in others.In this direction,Fundación Universitaria Juan N. Corpas, in Colombia, has been developing theidea of educating students—not only in Medicine, but across all disciplines—inSalugenesis, forming true “General Salugenists”: individuals trained tounderstand and accompany physical, emotional, and spiritual health processeswhile first practicing in themselves what they later teach others. In the nearfuture, I would be pleased to share with you our proposed “Health” CausalSalugenic Circadian Exposome model, currently under submission for publication.
There is substantialevidence that systems grounded in strong primary care and genuine generalistphysicians add more healthy years of life to populations than highly fragmentedand hyper-specialized systems. From this perspective, the subsequent durationof specialized clinical training could become a contextual and individualdecision: one, two, or more years depending on social needs and professionalaspirations.
For this reason, with all duerespect, I believe that the debate over whether medical school should lastthree or four years risks becoming merely an administrative discussionsurrounding a model whose foundational assumptions may first need to be reconsidered.The truly important question is not how long it takes to train physicians, butrather what we understand Medicine to be today, and what we ultimately want itto serve.
Thank you for this article. I am not familiar with what is happening in medical schools. Many of the arguments I hear against NPs and PAs have to do with the lack of education. I thought that the 4 years of medical school was classroom education along with clinical rotations, much as in nursing but longer and more intense. While nurses don't do long residencies, many who go on to get higher degrees have quite a bit of experience (in fact, it should be required - but that is a whole different argument).
I am sad to hear that we are not properly educating our physicians. I like your idea of focusing on critical thinking. This is so important.
Also, from Alex, below - it sounds like AI may be used much like we use the calculator. When I was young, we were told that if we used the calculator all the time we wouldn't know how to do math. Is that true? You be the judge. What happens when we rely too much on AI? How will it be relied on?
Many facets to this issue and the points you raise. Most everyone involved (government at every level, payers, employers, med schools, physicians and patients see the reality: too much being spent on healthcare, very difficult to see a primary care doc and all manner of medical tasks being offloaded to lesser trained professionals for the one reason we all know.So what's not to like about making med school quicker, and therefore cheaper, and increasing throughput.
The issue is that the health care system writ large that has created these problems need sto be changed on a fundamental level, or the outcome - the types of physicians in the specialties they choose, the priorities they choose as they proceed in to their adult lives - won't meaningfully change.
(Disclaimer: I retired from 35 years in primary care last year.)
Egads, no... We're already talking about replacing doctors with AI and now we want doctors Less qualified? Plus, we already have remote everything, likely a chunk of the present education length, and now we want Less education? Nope not me.
Beautifully stated. I was trained classically with the only wasted time "scut work," that actually wasn't that bad because it helped me find veins and it helped me quickly tell what was good for the patient. And I suppose it gave a little foretaste of our now much worse medical system.
Aside from the balderdash of woke and DEI requirements the worst criticism of contemporary medical education is that for the past ~30 years everything has been "teach to the test." I can count on 2 hands the number of students and trainees who could think. And this is not the fault of the students but of our leaders in education. Yes, our colleagues at ACGME, the deans, etc. They have harmed American healthcare, American patients, and American physicians. Too bad we can't vote them out.
I especially agree that doctors need to be pushed into critical / analytical thinking, especially regarding the analysis of clinical trials results. Too many simply focus on reading brief summaries that are highly biased and generally published by Big Pharma.
There is no way to fight AI in medicine, so training should include how to effectively and appropriately use AI in their medical practices, and how to double check the accuracy and reliability of their AI tools.
As long as you have doctors practicing medicine according to payment schedules, you will have mediocre care-at best.
The idea of going into medicine to make money has been poisoning the pool long before modern medicine took over. That has to be dealt with. Because the predominant desire to get rich cannot coexist with ethical principles.
If you cannot instill ethics in premed, no amount of medical training will be enough
Coming from a primary care angle thank for your opening paragraph. Absolutely. However I think it would help to be specific about "clinician" or "doctor". I tend to use "clinician" as any patient-facing professional? What is it doctors specifically need and what do all clinicians need? The more all stakeholders (including politicians and political advisers) have the same skills (particularly soft skills like shared decision making and risk communication) and same vocabulary about critical appraisal and value-based healthcare, the better. Otherwise how can they tackle today's knotty problems? High value care often requires teamwork and so does addressing low value care (hand-offs, changes in prescribing all done by "someone else"). Then of course the question is what can only one professional group do, compared to another.... Oh, and could there be mandatory elements like nicotine cessation and death certification.... globally these are rarely taught. Don't know the details of US.
Soooo…going outside the box a bit here. Eliminate the 4th clinical year and mandate two years of general medical practice in a public health setting for EVERY medical school graduate, in exchange for significant financial subsidy of their education. Several problems solved: school debt eased, primary care supported (and some docs may find they like it !), deeper appreciation for general practice demands by specialists of the future, less “ask your primary MD about your constipation” from specialists, etc. And if would-be physicians don’t want to do their share to support public health, well maybe they shouldn’t be physicians at all.
For Those Who Already Know: A Case for the 3-Year Medical Curriculum
I may have a unique perspective in this debate: I was the first graduate of LECOM's accelerated 3-year program, and I went into family medicine.
I didn't walk into medical school at 22 still becoming someone. I had a BS in bioengineering, an MSPH in public health, six years of marriage, two kids, and 27 years of life when I started. I hadn't gotten in right away — and what I did instead was grow. By the time I sat in that first lecture, I knew exactly what I was there for.
That changes everything about how you learn.
While my classmates took the first summer off, I kept working. When they returned in the fall, I was ahead. By February of second year, I'd finished the coursework most students complete in the spring. The whole time, I was shadowing a local family physician one day a month — not just observing, but building clinical identity in parallel with my education. I was coupling textbook medicine with real patients before I was ever credentialed to practice. My peers didn't see their first real clinicals until third year. My first full clinical rotation after Step 1, I was presenting differentials to attendings and running. That mentorship didn't fill a gap the curriculum left — it accelerated formation that was already underway.
I graduated at 30, matched into an excellent family medicine residency, and flourished. My program director told me I was one of the best bets he ever made.
The critics of shortened curricula assume that less time means less formation. But formation isn't a function of calendar years — it's a function of readiness. I didn't need four to six extra rotations auditioning at prestigious hospitals. I didn't need three neurosurgery rotations to confirm what I already knew. I needed to get out there and do the work I came to do.
Consider the inconsistency: we already accept that BS/MD early acceptance programs — which compress undergraduate education into two or three years — can produce excellent physicians. If we trust that premise at the college level, why does the logic suddenly fail when applied to medical school itself? It doesn't. The variable was never the calendar. It was always the student.
The financial reality matters too, and we don't talk about it honestly enough. My alternative would have cost $400,000 — debt I'd likely still be carrying twelve years later. LECOM, one of the lowest-cost private medical schools in the country, cost me $225,000, and that included portions of my prior degrees. I paid it off in six months after residency, between my signing bonus and moonlighting in my final year. That's not a footnote. That's the difference between a physician who practices where they're needed and one who chases income to service debt.
In an era when NPs and PAs are being granted expanding scope of practice, the argument for physician training shouldn't hinge on duration — it should rest on depth, rigor, and formation. Medical education, even compressed, produces better clinicians. But we'd do well to stop pretending that adding time automatically adds quality. We all know colleagues who coasted through four years and arrived at residency half-formed. The problem was never the curriculum length. It was that we're not honest enough about who belongs in the fast lane and who needs more runway.
The 3-year path isn't for everyone. One of my classmates didn't finish residency. The track is demanding and unforgiving, and it will expose every gap in your readiness. For the student still finding themselves, four years isn't wasted — it's necessary.
But LECOM's program has now been running and strengthening for over fifteen years. Programs that don't work get eliminated. This one grew. That's not sentiment — that's a track record.
Primary care has a workforce crisis, and we keep debating the wrong variable. The real question isn't how long medical school should take. It's how we identify and cultivate the people who are already becoming physicians before they ever apply — the ones whose life experience, maturity, and clarity of purpose have done the formation work that four years of curriculum tries to accomplish. We should be building pipelines for those people, not making them wait.
I was lucky. I had my life in order. I knew who I was and where I was going. That readiness was the real accelerant — not the shortened calendar. The 3-year curriculum didn't make me a physician. It gave someone who was already becoming one the chance to get there.
For those students, it's not a shortcut. It's the right road.
"We should be building pipelines for those people, not making them wait."
Couldn't agree more Dr. Keith. I mentioned similar thoughts in my comment below, but not as eloquently as you. The financial reality really looms large, especially with caps on loans, folks who are "nontraditional" older premeds with families as well as from mid/lower SES backgrounds.
This is so weird and coincidental. I was doing a short video about the problem in Indian medical education, where students no longer go to the wards, using The Pitt as a counter example, when I read your post and quickly incorporated a US Viewpoint.
I just posted it - https://youtu.be/BI-deuIIk70
You could shorten the amount of time needed for medical training by adopting a more European model - direct admission to medical school as an undergrad with a a 6-7 year combined program that results in an MD - eliminate summers off ( real doctors don't have summers off anyway ) , substitute regular 2 week vacation blocks and start clinical rotations after year 1 with gradual increase in responsibility. For those who drop out after 4 years an undergraduate degree could be given. This would allow for initiation of relevant anatomy, physiology and critical thinking and math skills at a much earlier time , and eliminate time spent in undergraduate elective studies that may enhance our lives as humans, but aren't particularly relevant to our lives as physicians. We are all smart enough to engage in art history , music and literature on the side if we wish . For those who don't wish, well they weren't benefiting much from enforced undergraduate electives anyway. This would also eliminate a lot of wasted summers pursuing unpaid internships, volunteer gigs, boring research studies all done to try to impress medical school admission committees in a desperate lottery to try to get into medical school . It would also allow less wealthy students to pursue medicine as they would not be forced to spend unpaid summers accumulating brownie points.
I would also propose that residency training and specialty designations should be completely overhauled and changed from " organ system ownership " to a more inpatient /hospital/critical care focused residency vs outpatient medicine . My field of OBGYN is especially in need of this - we can no longer be all things to all women over their entire life span. We need skilled obstetricians who can do deliveries , obstetrical surgeries , deal with medical disease and illness in pregnancy and function as hospitalists and community maternal fetal medicine physicians , leaving MFM fellowships to those few who wish to pursue academic and research carreers. GYN surgery should be it's own thing and oncologic gyn surgery should be part of that specialty , with true GYN Onc fellowship again limited to those wishing to pursue research careers. Those who want to care for women in an office setting could pursue one year of hospital training which includes minor office procedure training /surgery ( hysteroscopy, biopsies, colposcopy etc ) and then should focus on primary care for women with actual expertise in areas poorly covered in current training- HTN, DM, obesity, CV prevention, psych.
Go to the sensible system most of the rest of the world uses:
1 year pre-med, followed by 5 years medical school.
Obvious advantages are:
More clinical learning.
2 less years of tuition (perhaps smaller debts will encourage more to look at primary care?)
2 more peak earning years later in one's career.
What's the rush? A liberal arts education is valuable and I'd rather have medical students in her mid twenties then their late teens.
It doesn't matter much if they are late teens or early twenties. Everyone (almost) in India is in their teens when they start medical school. Perhaps it's a call to strengthen high school education so it provides the liberal arts foundation that kids are getting in college.
I think medical school education should be shorter, but I think the way to do it would be to offer more combined undergrad/medical school programs. These programs could be a total of five or six years. Undergraduate education could still be relatively broad, but with more of a focus toward medical adjacent topics, even in the humanities, philosophy, and ethics. Science and math classes could also be tailored and include statistical methods instead of super advanced calculus. And work and internship opportunities that many undergraduate participate in could be offered in medical settings to help students begin to have a sense of where they might want to specialize. But I also agree with you that the current approach to medical school education needs some revision and rethinking.
I totally agree. You have to read this one. I think you’ll like it.
https://sensiblemed.substack.com/p/reforming-medical-education?r=n8zko&utm_medium=ios
I am not sure if I understood. What do you mean by "Students would then concentrate on learning to evaluate medical evidence and master critical appraisal. Prioritizing these skills would steer people from reasoning based on pathophysiology to reasoning based on evidence. " ? I think that Medicine need much more physiopatologic reasoning. Black-box epidemiologic studies should not be regarded as producing medical evidence. To me, medical evidence requires physiopatologic reasoning, or it is not Medicine. It could be practiced by everyone.
Send me a DM and I will send you a copy of ending medical reversal. The whole book argues against that.
I'll push back from the other end: the USA needs to replace its 8-year system of college + medical school with the European system, in which medical education begins immediately after high school and people complete their basic training in 5-6 years. Too much of the typical U.S. undergraduate curriculum is irrelevant time-wasting fluff for students capable of becoming good physicians.
Dr. Cifu, Thankyou for your essay and for inviting reflection on the possibility of shorteningmedical school ( https://bit.ly/Cifu_2026_Shortening_Medical_School).
I graduated from asix-year curriculum structured around three years of basic sciences followed bythree years of clinical training, including hospital and ambulatory rotationsin Internal Medicine, Pediatrics, Obstetrics and Gynecology, and Surgery, withradiology, pathology, diagnostic reasoning, and therapeutics taughttransversally throughout the program. For decades, many have argued that evensix years are insufficient to “master” a profession whose body of knowledgegrows exponentially.
Yet paradoxically, that very curriculum often makes italmost impossible to understand the human being in his or her full dimension —or, more precisely, in every dimension except the humanistic one. Philosophy,ethics, sociology, anthropology, demography, history, geography, culture, andthe humanities in general are frequently treated as secondary distractionswithin the illusion of “saving lives,” or at best as ornamental subjects thatinstitutions themselves rarely embody in practice. Incidentally, why areschools of Medicine, Nursing, or Dentistry almost never housed within Facultiesof Human Sciences? Perhaps, then, thereal question is not whether medical school should last longer or shorter, butwhether we have correctly defined the ethical, anthropological, and epistemologicalpurposes of Medicine in the 21st century.
The debate over theduration of medical education seems secondary when compared to a much deeperproblem: we continue to train physicians within an epistemological frameworkinherited from the Flexnerian model of more than a century ago. A model that,while legitimately attempting to make Medicine scientific, ultimatelyconsolidated a fragmented view of the human being, reducing the person primarilyto a biological entity and reinforcing the Cartesian split between body andmind.Within this paradigm, Medicine progressively oriented itself toward thesymptomatic and diseased individual, treated in increasingly complex,expensive, and technology-driven hospitals by specialists and subspecialistscreated according to the demands of the healthcare market. As a result, theprofession became centered on the late containment of disease rather than onthe deep understanding of its causes and determinants.Paradoxically, much of Western “health care” functions more accuratelyas a “disease care business.” Genuine health promotion and profound diseaseprevention remain marginal because addressing the structural causes of illnesswould reduce the need for much of the interventionist industry that sustainsthe current system.
Premature specialization has significantly contributed to thisphenomenon. The four major specialties consolidated around Johns Hopkinscrystallized a model in which human problems became progressively divided intoorgans, systems, and procedures. We now even speak of training “generalistspecialists,” an expression that itself reveals a conceptual contradiction.Borrowing freely from the spirit of David Epstein’s The Range, one could say: “If you want a problem to grow,persist, and become insoluble, specialize exclusively in that problem.”
Therefore, before discussing whether medical school should last three,four, or six years, medical schools should first ask what kind of professionalcontemporary societies truly need. It is profoundly different to train expertsin the late management of disease than to train health professionals capable ofunderstanding, practicing, and teaching the conditions that promote theaccumulation of health.
Perhaps the early university years should focus less on memorizingever-expanding volumes of biomedical information and more on teaching studentshow to live healthfully, critically evaluate scientific evidence, understandthe determinants of health, think deeply, and cultivate a strong humanisticfoundation. A physician incapable of applying healthy principles to his or herown life will struggle to inspire health in others.In this direction,Fundación Universitaria Juan N. Corpas, in Colombia, has been developing theidea of educating students—not only in Medicine, but across all disciplines—inSalugenesis, forming true “General Salugenists”: individuals trained tounderstand and accompany physical, emotional, and spiritual health processeswhile first practicing in themselves what they later teach others. In the nearfuture, I would be pleased to share with you our proposed “Health” CausalSalugenic Circadian Exposome model, currently under submission for publication.
There is substantialevidence that systems grounded in strong primary care and genuine generalistphysicians add more healthy years of life to populations than highly fragmentedand hyper-specialized systems. From this perspective, the subsequent durationof specialized clinical training could become a contextual and individualdecision: one, two, or more years depending on social needs and professionalaspirations.
For this reason, with all duerespect, I believe that the debate over whether medical school should lastthree or four years risks becoming merely an administrative discussionsurrounding a model whose foundational assumptions may first need to be reconsidered.The truly important question is not how long it takes to train physicians, butrather what we understand Medicine to be today, and what we ultimately want itto serve.
Thank you for this article. I am not familiar with what is happening in medical schools. Many of the arguments I hear against NPs and PAs have to do with the lack of education. I thought that the 4 years of medical school was classroom education along with clinical rotations, much as in nursing but longer and more intense. While nurses don't do long residencies, many who go on to get higher degrees have quite a bit of experience (in fact, it should be required - but that is a whole different argument).
I am sad to hear that we are not properly educating our physicians. I like your idea of focusing on critical thinking. This is so important.
Also, from Alex, below - it sounds like AI may be used much like we use the calculator. When I was young, we were told that if we used the calculator all the time we wouldn't know how to do math. Is that true? You be the judge. What happens when we rely too much on AI? How will it be relied on?