"It's been more than 100 years since Abraham Flexner proposed the current model for medical education in North America," writes Dr. Richard Schwartzstein this month in the New England Journal of Medicine. That model is a four-year program: two years of studying science in classrooms, and two years learning by seeing patients in hospitals and clinics.
Those four years are just to get the doctor of medicine degree. For centuries, a physician would go straight into practice from there. Because today there's so much more to learn, though, and escalating demand for specialists, doctors don't actually practice until completing a residency. That involves clinical training of three to seven more years. And then, increasingly likely, a fellowship—one to three additional years.
Salaries during that period usually range from $40,000 to $65,000. By that point the average resident has a student-loan debt of $166,750 over their head. Half of doctors-in-training report that this debt influences their choice of specialty. (That's especially relevant since we have a large primary-care physician shortage in the United States. Within the decade, the U.S. physician shortage will be around 91,500, with about half of them in primary care. Efficient preventive and primary care is critical to lowering overall healthcare costs.) Some students who would go into primary care, one of the lowest-earning fields, feel they cannot make it work financially—especially if they began the education/training process later in life.
Percentage of U.S. Physicians Under 35 Years of Age (NEJM)
"Through slow accretion, years have been added to medical training," Drs. Ezekiel Emanuel and Victor Fuchs wrote last year in the Journal of the American Medical Association.
"In an era when unnecessary medical services are being intensely examined to reduce costs," they go on, "similar critical attention should be applied to eliminating waste from medical training, with a goal for US medical education to shorten training by 30 percent by 2020."
The Carnegie Foundation made a similar call for education reform in 2010, including that education should "provide options for individualizing the learning process for students and residents, such as offering the possibility of fast tracking within and across levels."
These ideas have since been implemented by a few U.S. universities (including New York, Texas Tech, and Mercer)—in limited capacities—in the form of a three-year M.D. program. McMaster and University of Calgary in Canada are also trying it out.
"The new three-year option is based upon an emerging national consensus that the model of medical education needs to address the changing scientific, social, and economic circumstances," NYU announced in December, "as well as the dramatic changes in the health care delivery system today."
(streetsofwashington/flickr)
Schwartzstein is a professor of medicine and medical education at Harvard and director of the medical school's Academy for Teaching Excellence and Educational Innovation. In his current journal article, he weighs in on the debate about the validity and prudence of this three-year model.
Since 1975, the percentage of physicians who are younger than 35 years of age has decreased from 28% to 15% as the prolongation of specialty training has delayed entry into the workforce, reducing the productive years of clinicians and physician scientists.
...One benefit of shortened training, whether at the premed, undergraduate medical education (UME), or GME stage, is to help reverse the trend of physician "age creep." Although shortening UME training alone will not increase the number of graduating physicians, it will allow graduates to enter practice sooner and thereby increase the physician-years in practice on the national level, helping to address the shortage.
... As an increasing number of medical schools adopt a three-year pathway, residency programs will probably begin accepting fast-tracked students from other programs, perhaps through a consortium, extending the possibility of tracking learner data along the UME–GME continuum across institutions.
Another benefit of a 3-year pathway is its effect on reducing the student debt burden. [The programs cost 75 percent as much as a four-year path].
... Concerns about a 3-year pathway include the sense that ... the fourth year ... can be a valuable maturation period for many students, providing opportunities for research or additional clinical exposure. Related concerns include the potential loss of exploration and enjoyment in the medical education process.
It is essential that physicians enjoy the process to some degree. Would shortening medical school (thereby decreasing student debt burden) do more on average to help the burnout epidemic, or to worsen it?
Schwartzstein concludes that the need for medical education reform is generally agreed upon at this point; the only question is how best to do it.
(ABC)
The debate is ultimately about an evolving understanding of what it means to be a physician. Selecting intellectually curious applicants and training students to expect to learn throughout their careers seems the common consensus. Emanuel and Fuchs said it well: "For decades, the ideal academic physician has been the triple threat: an incisive diagnostician and empathetic clinician, a productive researcher, and a scintillating teacher." (Some could also sing, dance, and act—like Neil Patrick Harris, TV's Doogie Howser, M.D.—a sextuple threat.)
"Similarly, the clinical practitioner was supposed to be omnicompetent, capable of managing all illnesses," they continue. "The consequence is a broad training regimen that includes mandatory research experience for all physicians, and emphasizes the autonomy of the physician rather than team-based care." Even Howser, despite graduating from Princeton at age 10, took a full four years to complete medical school.
In new systems of education in training, the necessary concession, Emanuel and Fuchs say, is to admit that "no physician can be a competent triple threat. ... No single clinician can know everything even in his or her own specialty."
The modern physician is not omnicompetent. Ideally they've had time to learn as much as possible, and become great at communicating and understanding the body and the world, and maybe even gotten a Ph.D. in the area of a patient's particular concern. Maybe they've even spent a few years editing a national magazine, for ... worldly perspective? But it won't be the norm. At best the modern healthcare team can be omnicompetent; each physician, nurse, therapist, and social worker—working to care for a patient—has a specific area of excellence.
The new physician ideal is confident but openly limited, fallible, and always a student.
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Walt is walking nostalgically through his precious drug factory. We see police cars approaching in the background. Badfinger plays. When the policepeople reach Walt, presumably not long after, he is sprawled like a starfish martyr, supine on the concrete floor.
A little too picturesque, don't you think?
Walt was shot in the abdomen. I will believe that he is dead when I see a flat line on his ECG and a close-up of his flaccid jugular vein. He did not go from walking around to bleeding out in a matter of minutes. Nor is there enough blood to suggest it. Walt was lying face down on top of Jesse when the bullet entered him from his right. If the bullet perforated his bowel and he became septic, emergency surgery could still save him. If it seriously damaged his aorta, he would've either died more quickly or still been amendable to resuscitation.
In an interview immediately following the show, creator Vince Gilligan answered questions that conceded the premise that Walt was "dead." Don't forget that Walter White is one of the greatest criminal minds of our time; a master of deception. What makes Gilligan immune? No no; the police scoured the lab for imminent threats, then returned to perform CPR on the still-warm victim.
Five seasons and a movie. This franchise has too much profit potential. Without it, Aaron Paul will make movies like Need for Speed. No one wants this. The feature film will open on Walt recovering from emergency surgery in a sunny hospital room. On his bedside table is a brown paper bag. Inside? You guessed it: blue meth. The stuff is pure. And, what's this? It's a note: "Hello, Walter"—signed by Gus Fring and Mike Ehrlentraut.
"Oh boy, how long was I out?" Walt thinks, laughing.
"This must be an old note," he says aloud. But then he notices that the note is written on a copy of that morning's Albuquerque newspaper.
Cue theme song.
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