Shortening Medical School Will Not Improve Medical Education

A bit of a rant

This article began as a Twitter comment in which I disparaged arguments that medical schools should embrace the move from 4-year to 3-year curricula. About 15% of schools now offer the shortened course of study. These include NYU, Penn State, Duke, and UC Davis. I offered up a 500-word Sensible Medicine debate but didn’t get any takers. (I get it, we’re all busy, no shade cast here.) I still wanted to make my argument, so here it is. If anyone wants to argue for the shorter curriculum, send me a < 700-word essay. (Maybe write it before you even read any further. I think an argument would be more interesting than a rebuttal.)

Medical education needs to change. It needs to produce more generalists. It needs to produce specialists with generalist skills. It needs to produce doctors who can assess evidence and deliver high-value, patient-centered care. It needs to produce doctors who recognize low-value care and are willing to counsel patients to avoid it.

Reducing the duration of undergraduate medical education (medical school) to 3 years is not the way to achieve these goals.

Debating aspects of medical education always requires data-free argument. This is because there is no “gold standard” for measuring physician quality. This fact was best stated by Lawrence Weed in 1981:

To say that physicians are good or bad would be to imply that there are well-accepted standards of performance and random audits to judge them by; but there are none. Their nearly total freedom to determine the context of their professional activities and their own standards within this context, especially in the private office where much of medicine is practiced, precludes any rational conviction about the effects of their efforts.

In arguing for retaining the 4-year medical curriculum, I am not defending the current curriculum, which has become wholly inadequate. The Flexnerian schedule gives us 2 years of preclinical science followed by 2 years of clinical experience. Over the last 20 years, preclinical education has been weakened by the inclusion of unnecessary courses, research experiences important to a small minority of students, and time off for USMLE preparation. The clinical years, once rich in mentored clinical experiences, are now defined by passing encounters with attendings doing brief stints on inpatient services. The final months of the curriculum are a wasteland, an expensive vacation, inexcusable since residency interviews are mostly done remotely. Most students at medical schools with 4-year curricula receive 3 years of education while being charged 4 years of tuition. I understand why people want change.

What we get from this system are graduates who lack patient-centered general knowledge. They are adequately prepared for specialized residencies that usually prepare them for even greater specialization. This is one reason we suffer with expensive healthcare that yields mediocre outcomes. Most doctors are uncomfortable reassuring patients with benign concerns outside their expertise. This leads to endless streams of unnecessary tests and referrals.

We fail to train generalists because we do not teach young physicians to adequately assess the medical literature. Our trainees rely more and more on conflicted guidelines and studies designed to yield bigger profits rather than better care.

We have outlined one possible curriculum that we think would decrease the risk of future medical reversals and increase the practice of sensible medicine.¹ Briefly, such a curriculum would begin teaching students the basics of normal and abnormal human anatomy and physiology. 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. Clinical experiences rich in deliberate, evidence-based mentorship would follow. These experiences would be labor-intensive and costly, but this is where tuition money should be spent. The final year of the degrees program would have students engage in courses more tailored to their specialties — advanced anatomy for surgeons and radiologists, clinical reasoning and interviewing skills for internists and pediatricians...

I have outlined ways to shorten a medical school curriculum to 3 years, but this requires wholesale reform of post-college, premedical preparation.² It cannot be done as it is now, with cuts and compression, at a time when medical knowledge is growing exponentially, and AI threatens to undermine students’ efforts to learn what they need to. Medical education needs to improve. Shortening it and then using poorly designed studies to prove we have not damaged it is not the way forward.

1. One version is in chapter 14 of Ending Medical Reversal. (Yes, you should drink if you are playing the game of a shot every time I promote EMR or The Case for Being a Medical Conservative.)

2. Way back in 2022, we asked people to share ideas for medical education reform. They make for good reads. Medical Education Reform Part 2. More Problems with (and Suggestions for) Medical Education.