Why The Length Of Medical School Matters — But Not In The Way You Think

Health care reform has dominated headlines with news of hospital acquisitions, medical innovations, and most recently, the government standstill in response to changing insurance coverage. While crucial, however, these topics overshadow another issue affecting our nation’s health: the length of medical school.

Understandably, most people have never considered the implications of lengthening or shortening medical school. Most know it is part of a long career path that compels students to study intensely and endlessly. Most assume that it teaches students all the appropriate material in appropriate depth. To most, the MD degree is a reliable standard of expertise.

While few can agree on what topics merit what proportions of curricular time, most know something must be omitted. Students simply cannot learn it all in four years.

But medical school education is actually much more variable. Most schools keep students in the classroom for two years, and in clinical sites for another two. Some, however, compress and rearrange material, creating unique requirements. As a result, some learners gain broad exposure to clinical areas while others receive almost none. Some trade clinical electives for research or international experience. Many have extended periods of free time. None graduate with the exact same expertise or experience.

This would be fine — tailored training marks every profession — except that the body of medical knowledge continues to grow exponentially. This is partially because biomedical science is generating discoveries more rapidly than ever before. Between advances in areas like genetics, radiology, and biomaterials, modern doctors must know far more than their predecessors.

It is also partially due to growing pressure to teach traditionally ‘non-medical’ topics such as management, quality improvement and cost effectiveness. These are topics that doctors from generations past never learned, much less mastered. But they are integral parts of our present reality, of doctoring in the era of cost containment and reform.

This is why the length of medical education is important. Scientists assert that students need research experience to succeed, while administrators emphasize health economics. Medical humanities, bioethics, and evidence-based medicine all claim their stake and importance. But while few can agree on what topics merit what proportions of curricular time, most know something must be omitted. Students simply cannot learn it all in four years.

And maybe they shouldn’t have to. Some schools are offering compressed, three-year degrees based on the belief that medical school can be shortened without hurting educational quality. Proponents maintain a noble and achievable goal: to decrease financial burdens on students and increase the workforce in high need areas like primary care. Opponents argue that these attempts fatally disrupt core elements of medical education. While cogent, however, these arguments fail to frame the issue within larger educational perspectives.

First, they do not provide the wider context of change that already exists in continuing medical education. Training has already transformed drastically for young and experienced doctors alike. New MDs face significant work hour restrictions, and older doctors must re-certify for licensure more frequently than ever before. They must learn more in less time and undertake more iterative, incremental learning throughout their careers. For better or worse, they must accept these changes as part of a new future in which they complete portions of training knowing far less than their predecessors in some areas, and more in others. Ultimately, this has less to do with the length of medical training and more to do with a spirit of continual learning.

Second, these debates don’t fully consider perspectives from needs-based educational approaches. The American preference for all students to obtain college degrees may correspond to the desire to provide all medical students with broad educations and make them “more well-rounded.” But experience suggests that this is not always the only or best approach. The Germans, for example, effectively employ a dual system that produces skilled university graduates on one hand, and skilled vocational workers (e.g. watchmakers, chefs, electricians) on the other.

The age of individual doctors wielding encyclopedic knowledge and operating in isolation is ending.

Would similar types of shorter "tracks" gain traction within medical schools? Could they produce the volume and caliber of doctors our country needs? It remains to be seen. But with the growth of interconnected health systems and team-based medicine, it may prove a worthy consideration. Despite uncertainty about how reform will exactly impact health care, one thing is clear: the age of individual doctors wielding encyclopedic knowledge and operating in isolation is ending.

Whatever system rises in its place will require doctors to function within narrower roles and more sophisticated systems. It will require new skills and definitions of doctoring. It will therefore require graduates trained in competencies based on patient needs, not whatever amalgamations of biomedical knowledge is compressible into three, four, or any other number of years.

In the end, the length of medical school is not really the main issue. Instead, the true challenge facing today’s doctors is to embrace an unfamiliar future defined by new expertise and deficiencies, to encourage continual, incremental learning, and to teach things that address the emerging needs of our patients.