Rethinking Medical Education

Last spring, in his elegant commencement address to the Harvard Medical School, Dr. Atul Gawande appealed for a dramatic change in the organization and delivery of medical care.  His reason, “medicine’s complexity has exceeded our individual capabilities as doctors.”  He accepts the necessity of specialization, but he criticizes a system of care that emphasizes the independence of each specialist.  Dr. Gawande is not alone in thinking that scientific, technologic, and economic changes require reorganization of care.  Larry Casalino and Steve Shortell have proposed Accountable Care Organizations (ACOs); Fisher, Skinner, Wennberg and colleagues at the Dartmouth Medical School have focused on reforming Medicare, and many others have also called for major changes.

I expressed similar concerns in 1974 in my book Who Shall Live?, but at that time I rejected the claim that the problems of medical care had reached crisis proportion.  In 2011, however, I agree with those who say the need for comprehensive reform must be marked URGENT.  The high and rapidly rising cost of health care threaten the financial credibility of the federal and state governments.  The former finances much of its share of health care by borrowing from abroad; the states fund health care by cutting support of education, maintenance of infrastructure, and other essential functions.  These are stop-gap measures; neither borrowing from abroad nor cutting essential functions are long-run solutions.  The private sector is equally distressed.  Surging health insurance premiums have captured most of the productivity gains of the past thirty years, leaving most workers with stagnant wages.  Not only is there a pressing need for changes in organization and delivery, but Ezekiel Emanuel and I, in our proposal for universal vouchers funded by a dedicated value-added tax, argue that such changes must be accompanied by comprehensive reform of the financing of medical care (Brookings paper).

But that’s not what I want to talk to you about today.  My subject is the urgent need to change the structure of medical education.  It seems to me that such change is necessary, and perhaps inevitable, given the revolution in medicine over the past half century, and given the changes in organization and delivery of care that lie on the horizon.

The need for change

Consider the deluge of new medical technologies in recent decades.  According to Dr. Gawande, in deciding on interventions for their patients, clinicians now must choose from 6,000 drugs and 4,000 procedures.  To be sure, many of the 6,000 are not new chemical entities but rather combination drugs, alternative dosage forms, and other variations.  Still, the burden on the clinician to make an appropriate choice is great, especially if, as stated in the Physician Charter, “physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.”  Economists have been touting cost-effectiveness for years, but it is a harbinger of change to see organizations representing more than half of all active physicians sign a charter committing them to practice cost-effective medicine.

Along with the new technologies, there has been a proliferation of specialties and sub-specialties.  Fifty years ago, there were 18 specialty boards and very few sub-specialties.  Now there are 36 specialty boards and 116 sub-specialty certifications, for a total of 152.  Does such proliferation provide much or any benefit to patients?  The United Kingdom has only 97, while, Canada and France have fewer than half as many.  Proliferation of specialties and sub-specialties almost certainly adds to the cost of medical education and the cost of care, while its effect on quality of care has not been systematically investigated.  The former chair of medicine at a major academic medical center thinks it has an adverse effect on patient care, but other experts disagree.  We just don’t know the answer.  If empirical studies conclude that so many sub-specialities are desirable, the training structure that produces them should and could be made more efficient.  Medicine is one of the few fields that requires specialists to have more training than generalists.  This may have been rational at one time, but may not be today.

Finally, and closely related to the new technologies and increased specialization, there is the soaring cost of medical care.  In 1960 U.S. health expenditures, in 2009 dollars, were $864 per person.  In 2009, they were $8085.   Along with the cost of medical care, the cost of medical education has increased exponentially.

In the face of such revolutionary changes, how has the structure of medical education adapted?  It seems that the answer is hardly at all.  Fifty years ago, the basic structure was four years of college, four years of medical school, and three years of post-graduate training.  Only after 11 years of post-high school graduation was the physician deemed ready to practice medicine.  The same is true today, although a much larger percentage than formerly go beyond 11 years to obtain additional specialized training.  And in one medical school I know of fewer than 40 percent graduate in 4 years.

The goals of change

A reasonable goal for structural reform might be to reduce that basic period from eleven to nine years.  This can be done by cutting time off the front end or the back end of the process or both.  About the front end, I note that there are now 33 medical schools that combine college and medical training in six years.  Could there be more such schools?  What is known about the quality of care delivered by physicians from these programs compared with the graduates of conventional medical schools?  Very little.  Most other developed countries combine college and medical school in one program that is typically less than eight years long.  Are their physicians inferior to American physicians?

It might be argued that foreign medical schools can admit students directly from high school because the educational achievement of those high school graduates is greater than that of  American high school graduates.  This is probably true on average, but there are certainly some American high school graduates with educational achievement equal to those who graduate from foreign high schools.  Why couldn’t American medical schools consider for admission applicants who, through appropriate examinations and interviews, appear to be as well qualified as the college graduates the schools are now admitting, regardless of how many post-high school years the student has completed?  I understand that thoughtful leaders in medicine are studying various possibilities for accelerating admission to medical school for qualified candidates.  That’s great.  But I hope they realize that the health care system is entering the “ICU;”  prompt, decisive action is needed.

In order to reduce time at the back end, schools might consider accelerating choice of specialization.  Dr. Gawande notes that there was a time when “doctors could hold all the key information patients needed in their heads and manage everything required themselves.”  He says that in such a world it made sense for physicians to prize “autonomy, independence, and self-sufficiency.”  But that time is gone forever.  What remains is a structure of medical education based on those outmoded assumptions.  For Dr. Gawande, who is as handy with a metaphor as with a scalpel, the bottom line is “we train, hire, and pay doctors to be cowboys.  But it’s pit crews people need.”

A proposed new structure

If Dr. Gawande is correct, what does this imply for the structure of medical education?  Isn’t it time to give up the conventional wisdom that pouring more and more knowledge into each physician about more and more subjects will produce a better system of medical care?  Far from rejecting specialization, embrace it sooner.  For the purpose of stimulating discussion, I propose the following structure for medical education:

  • Two years of medical education taken by all students.  This common curriculum would consist of 50 percent basic science with an emphasis on competencies that would be useful to every physician.  Subsequent exposure to basic science would depend on its relevance to the student’s prospective career.
  • One-third of the time would be devoted to an introduction to clinical care of individual patients, making as full use as possible of modern technologies that have been successful in training programs in industry, the armed forces, and other settings.
  • One-sixth of the time would be used to cover key aspects of the health of populations and the organization and delivery of care, with emphasis on a team approach to enhance health.  It is important for all physicians, regardless of prospective careers, to understand how each element fits into a health care system.

Upon completion of the two years, each student would select a track which launches him or her into the world of specialization.  Here is an example of what the tracks might look like:

  • Leaders of primary care teams, possibly sub-divided into adult care, pediatric care, and geriatric care.
  • Clinical specialists in medicine, hospital based and ambulatory.
  • Clinical specialists in surgery and other procedural specialties.
  • Possibly another track for those headed for specialities such as radiology and pathology that treat medical and surgical patients.
  • A track for students whose major interest is research, possibly similar to current MD-PhD programs but with explicit recognition that the trainees are not preparing to be clinicians.

The content of the training program would differ depending on the track.  For example, students training to be leaders of primary care teams would be exposed to more statistics, epidemiology, preventive medicine, and management skills than those in the other tracks.  They would learn how to deploy nurse practitioners, physician assistants, and other non-physicians most effectively.

Is it feasible for students to make specialty decisions sooner than they do in the present structure?  Before you answer with a resounding “no”, let me tell you a “tale of two schools.”

A tale of two schools

Just a stone’s throw from the Stanford School of Medicine (if you have a good arm) is the Stanford School of Engineering.  The latter school accepts students after they have completed two years as undifferentiated Stanford undergraduates.  Prospective students of engineering are encouraged to take a wide variety of courses during their first two years at Stanford, but are also advised to make sure they are getting a good start toward engineering through courses in mathematics and science.  At the beginning of their junior year the engineering students declare which of 17 fields they plan to specialize in.  The fields range (alphabetically) from Aeronautics and Astronautics to Product Design and include such well-known specialties as Chemical, Civil, Electrical, and Mechanical Engineering.

Notice that the choice of specialization is made two years after high school graduation.  I may have said that too rapidly.  Let me repeat it.  Two years after high school, engineering students at Stanford commit themselves to one of 17 specialties.  At MIT students must choose their specialty at the end of their freshman year.  The heavens do not fall.  The SAT scores of the engineering students suggest that they are intellectually about equal to the Stanford medical students.  The School of Engineering helps students learn about the various specialties by offering 20 seminars on different subjects with enrollment preference given to freshmen.  Examples of seminar subjects are: “Bioengineering Materials to Heal the Body,” “Digital Dilemmas,” “Water, Public Health and Engineering,” and “What is Nanotechnology?”.  An additional 12 seminars are offered on other subjects with enrollment preference given to sophomores.  Examples of their titles are: “Electric Automobiles and Aircraft,” “Environmental Regulation and Policy,” “Medical Device Innovation,” and “The Flaw of Averages.”  These seminars provide an opportunity to work closely with faculty.  In addition there are many one-unit seminars that provide exposure to key issues and current research in various fields.  At the end of four years at Stanford, approximately 80 percent of the engineering students graduate with a bachelor’s degree and enter the workforce to practice their specialty.  Students who go on for a fifth year typically do so in order to earn a master’s degree.

There are of course, many differences between engineering and medicine.  Biologic systems are probably more complex than the systems engineers work with, and causal relations are less firmly established.  An alleged difference is that physician decisions affect life and death, but the same could be said for many engineers.  The men and women responsible for our bridges and tunnels, the design of our airplanes and cars, the safety of our water supply, and many similar functions are surely making decisions that affect life and death.  One of the biggest differences is that engineers specialize from the start of their training; they are not expected to know about all aspects of engineering.  They typically work in team settings.  They are, to use Dr. Gawande’s words, “pit crews” not “cowboys”.  Collectively, they get the job done.  Perhaps the biggest difference is that when a medical student chooses a specialty, he or she is usually choosing a life-time occupation.  For an engineering student, life-time occupation is not as closely linked to choice of specialty training.  One reason for persistence by physicians in a certified specialty is that diminished competition affords the specialist the opportunity to earn a “monopoly rent.”

Training sub-specialists

As an example of how specialty training in medicine does not have to take as many years as tradition demands, consider Dr. Robert Chase’s experience in training plastic surgeons at Stanford.  When he began his program, plastic surgery required completion of residency in general surgery followed by another residency program in plastic surgery.  The combination took a minimum of seven years and more often eight or nine.  Drawing on his experience as chief resident in general surgery at Yale, a two-year fellowship in plastic surgery at the University of Pittsburgh, and active duty in the Valley Forge Army hospital, Dr. Chase was pretty sure he could train plastic surgeons in no more than 6 years and often in four or five.  To this end he developed an integrated program that started residents headed for plastic surgery side by side with residents headed for general surgery.

The idea was rejected by the American Board of Plastic Surgery, but he pursued it anyway.  Fortunately, the first residents to complete the program did so well at both the written and oral examinations that the Board gave tentative approval to the program.  Today there are 27 truly integrated programs similar to Stanford’s, and another 62 that combine general and plastic surgery; only 27 of the traditional programs remain.  It would be surprising if similar shortening could not be accomplished in other fields of medicine and surgery.  What is required is an exceptional clinician-teacher who is willing to confront the established powers and prospective specialists who are willing to commit sooner to their specialty.

Arguments against and obstacles to restructuring

Until now, medical education has proceeded under the premise that “Keeping one’s options open” is a free good.  It is not; and the costs to the individual and society increase every year.  Those who set the rules and requirements must consider the possibility that what their generation had to endure may not be the best path for the future.  Many of the existing rules and requirements seem to be based only on “tradition”.  The same academic physicians who would not prescribe a drug without determining efficacy and safety, have no hesitancy in prescribing the structure of medical education without any studies that examine the appropriateness of that structure relative to alternatives.

Changing the structure of medical education will not be easy, even for those who are enthusiastic about the goal.  Opponents will be numerous, and the arguments varied.  Many of the most popular ones are not persuasive.  Consider the cliché, “If it ain’t broke, don’t fix it.”  The existing structure may not be “broke”, but it provides the intellectual foundation for a medical care system that is causing the rest of the country to go broke.  Some will say that my suggestions are “controversial.”  I agree.  For more than fifty years I have observed and participated in attempts to reform college curricula, and I can tell you that reforms that are not controversial are inconsequential.  Some will want to take credit for the gain in life expectancy of 8.4 years over the past half century.  But other developed countries with different systems of medical education and medical care have achieved even greater gains and are at a higher level, while their per capita spending on medical care is 35 to 50 percent less.

Two possible objections to changes discussed in this lecture are that they threaten the deeply held (albeit antithetical) visions of the physician as scientist and the physician as humanist.  The threats are real, but the visions are increasingly unreal.  American medical education is at a cross-road: Shall it continue to strive to produce scientists-humanists or recognize that what society needs most at this time are competent professionals, capable of providing leadership and supervision for the more than 15 million individuals now employed in the delivery of health services.  The challenge to the leaders of medical education is to figure out what kind of admission policy and what structure and content of medical education, undergraduate and post-graduate, will produce such professionals at a reasonable cost  It could be correctly argued that the cost of medical education is a relatively small part of the total cost of medical care, so why change medical education? The reason is that a restructured admission policy, earlier specialization, and shorter period of training can contribute to producing a different physician, one better suited for a team approach to remedying the cost, access, and quality problems now evident in American health care.

The obstacles to change will be partly external to the medical education establishment and partly internal.  Consider, for example, the dense network of laws and regulations that now govern the practice of medicine.  Some are federal, most are state, and often differ from one state to another.  Those that are worth preserving should be federalized.  These laws and regulations have been passed with the present structure of medical education in mind.  Change in that structure will require changes in the existing legal framework.  Many of the laws were enacted with the stated purpose of “patient protection”, but as is true in so many industries, they often wind up giving providers protection from competition.

Consider also how malpractice attorneys will leap on health outcomes that fall short of ideal and try to tie these lapses to changes in medical education.  We badly need a better system of dispute resolution to replace malpractice suits.  Consider also, how large insurance companies and hospitals will resist change, not necessarily because the change would harm them in the long run, but because change is usually disruptive and costly in the short run.

Perhaps the biggest obstacle to change will be within the medical education establishment which includes not only the medical schools but also post-graduate training programs and the bodies that control certification for 152 specialities and sub-specialties.  Are all these necessary?  Restructuring will undoubtedly require some faculty to change what they do and some faculty may be redundant.  Many specialty and sub-specialty boards will need to change their criteria, as in the case of plastic surgeons.   In some areas it may be difficult at first to find medical educators well-equipped to meet the needs of students in the new structure.  For instance, where will medical schools find instructors to train the students who have opted for the track of leaders of primary care teams?

Finally, there is the chicken or the egg problem.  There are medical leaders who see the need for significant changes in the financing, organization, and delivery of care.  But they feel stymied by the absence of physicians with the preparation and attitudes necessary to be most effective in the new systems of care.  There are leaders in medical education who see the need for significant changes in structure and content, but wonder where the graduates of the new programs will find appropriate employment.

All these obstacles suggest that restructuring may be impossible.  But I draw some hope from an observation made by Alexis de Toqueville who said, “The United States moves from the impossible to the inevitable without ever stopping at the probable.”

This is the end of my jeremiad.  If I have offended any readers, I apologize.  That was not my intent.  I have, for many decades, studied the American health care system, focusing on the high cost, the inequalities in access, and the lapses in quality of care.  I concluded that these problems will not yield to piecemeal reforms.  What is needed is comprehensive change in the financing, organization, and delivery of care.

But I have not paid much attention to medical education.  Dr. Gawande’s Harvard commencement address made me realize that reform of the health care system must be accompanied by a restructuring of medical education.  Hence this lecture.  Perhaps my suggestions for restructuring are off the mark.  Some may have better ideas as to how it should proceed.  If so, all to the good.  If I have convinced you of the urgency of the task and stimulated you to address the problem, my effort will not have been in vain.  I greatly appreciate the opportunity you have afforded me, and I thank you for your patience.

I await your questions with interest and a reasonable amount of apprehension.

Victor Fuchs is the Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy, emeritus, an FSI senior fellow and a core faculty member at Center for Health Policy/ Center for Primary Care and Outcomes Research at Stanford University. He has written extensively on the cost of medical care and on determinants of health, with an emphasis on the role of socioeconomic factors.

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25 replies »

  1. Thanks for this. I had forgotten about this comments thread. You raise a valid question:

    One last note about trending away from “cowboy” physicians to “pit crews”- wouldn’t narrowing one’s medical knowledge and increasing reliance on colleagues in other specialties further increase costs? We know that specialist physicians are the highest paid under the current fee for service system. If medical education emphasized learning a limited knowledge base in order to graduate sooner, it seems it would enable a mentality of essentially passing the buck to peers in other specialties. If a primary care physician did not feel comfortable handling a patient with multiple health issues due to a shortened clinical education, it seems that referrals would be the most he or she could do in order to help a patient.

    The present system operates very much like you say — specialists become star attractions, but mostly because they are few and far between, and there is not an economy of scale (or in the case of hospitals, volume within specialties) which result in lower costs for the same reason that the first hour of any business is always the most expensive until the rest of the day’s volume justifies opening the door. Stated another way, if a medical specialist and a colleague have enough to keep them busy all day, every day, then an economy of volume will bring costs down, not up.

    This post is excellent but it’s now two and a half years old. Since then a variety of “business models” have started to emerge. This is a good time to reflect on professor Fuch’s ideas in the light of this recent post by Nick Dawson.


    Aravind Eye Hospital in India does more eye surgeries than any other place in the world. It treats nearly 2 million patients a year, for remarkably less than most hospitals in the United States, and it treats nearly two-thirds of those patients for free.

    It is generally regarded as one of the best facilities for eye care quality in the world.
    …where I live in Richmond, Virginia, we have 11 licensed hospitals. Eight of which are large, traditional community hospitals and one is a large academic medical center. Of those eight, seven offer most of the same services: OB, general surgery, diagnostic imaging, orthopedics, emergency care, etc.

    At the risk of sounding anti-capitalistic, does it make sense for seven hospitals to all do the same thing, with different processes, standards, outcomes and costs? Or might I be better off flying to India for my eye surgery?

    My point in these vignettes is to consider the globalization of treatment options. As our world gets smaller, our ability to specialize treatment options and concentrate them into true centers of excellence becomes not only a reality, but an important consideration.

    In fact, the VA has had this model for many years. The VA recognizes it is better for quality and costs to concentrate expert providers in key centers, and move patients and families to those centers for treatment. We also see this today in cancer care. May patients, albeit most often those with resources, consider traveling to the Kennedy Center, Sloan-Kettering, MD Anderson or Stanford.

    You can see where this is going.

  2. I’m a second year medical student so my perspective is understandably limited, but here’s my take.
    Really interesting article, and I agree there is a lot of redundancy in medical education. However most of the focus seems to be on culling from the clinical side of medical education rather from the more redundant (in my opinion) undergraduate side. Personally I do not think I would be an optimally trained surgeon if I had little to no experience in internal medicine and other non-surgical fields (and vice versa). The article speaks to the importance of being part of a health care delivery team, but essential to teamwork is understanding roles and appreciating what tasks others on the team do, and when those tasks are appropriate. Significantly reducing exposure to different fields (and patient populations) in order to fast-track someone into a specialty is both unfair to the physician (depriving him or her of essential clinical experience) and the patient. However, many aspects of undergraduate education are entirely redundant; the biochemistry chapter of First Aid (a ubiquitous USMLE Step 1 prep book) paraphrased several months of my undergraduate basic science curriculum. We don’t really need four full years of undergraduate education in order to understand our medical curricula, as evidenced by foreign medical graduates who finish combined baccalaureate/MD programs in about 6 years. One could even argue that those candidates are better trained than we are because at a given post graduate year, they have more clinical experience than American graduates.
    One last note about trending away from “cowboy” physicians to “pit crews”- wouldn’t narrowing one’s medical knowledge and increasing reliance on colleagues in other specialties further increase costs? We know that specialist physicians are the highest paid under the current fee for service system. If medical education emphasized learning a limited knowledge base in order to graduate sooner, it seems it would enable a mentality of essentially passing the buck to peers in other specialities. If a primary care physician did not feel comfortable handling a patient with multiple health issues due to a shortened clinical education, it seems that referrals would be the most he or she could do in order to help a patient.

  3. After reading this article i strongly agree structure of medical education need structural reform.The structure propsed by you seem effective to bring educational change.

  4. Hello,
    My name is Dave and I am a 4th year medical student. In my limited understanding of the health care crisis, I think this blog captures what I know of the big picture. One thing I don’t understand is something that southern doc mentioned. Often in my 3rd and current 4th year rotations when caring for patients as a primary provider I get frustrated. I often feel like the hamster on the hamster machine spinning the wheel when a patient with CHF, DM, HTN, and CKD has a cardiologist telling me to start lasix, the nephrologist tells me to DC the lasix an hour later. The podiatrist tells me the patient is going to the OR to remove a gangrenous toe even though the patient needs a BKA. Another confusing issue to me is that I am hammered constantly about how to handle the problem list but I am told to order consults. I do not understand why cards, nephro, and podiatry get consulted but endocrine does not. It certainly seemed like non-compliance and DM was the primary problem.

  5. awesome thought professor, first I thank for this article, All medical students must need to read this article.

  6. Who will bell the cat ?
    Medical education is at the crossroads and as Prof Fuchs says, well thought but urgent solutions are needed. We are following the bearers of the torch of learning, that was handed to the Americans( Halstead, Osler ,Welch,Kelly,among a galaxy of greats). Prior to that the Germans lead by example with Langenbeck (the father of the surgical residency ) ,Billroth ,Kocher and others .The Indian medical education had my mentor Prof B Ramamurthi calling for reform and he pushed for a direct 5-6 year programme to train neurosurgeons.His stand has been vindicated.Perhaps international boards are the future and with an inbuilt evolution clause to allow for constant correctives.I congratulate Dr Gawande and others for the belling of the cat..
    Dr Anil Pande Neurosurgeon, India..

  7. The diseases, their cause, and their complexity have not changed yet we continue to invest in more and more complex and expensive ways to treat them. Readers of this article looking to better medical training should also read the one above it, “YOU ARE SOLVING THE WRONG PROBLEM”

    Doctors should be advocates for prevention not treatment.

  8. Respectfully, maybe it is time for people to stop taking on clinical matters that are outside their training. Telling people to “deal with it” is just validating poor judgment. And, I practice what I preach, I do not treat diagnostic issues in my office I am not able to manage for weeks to months. Another example of one reason why health care is eroding like sands on a beach during a Nor’easter, everyone just doing what is told and not responding to trained boundaries.


  9. As a family doc, I have so many sub-specialists think they can diagnose the problems, more often just complicate it with reckless procedures, then literally dump it on me to “fix it”

    If you haven’t learned that it’s a two way street, you’re not paying attention. I see your failures, you see mine. Deal with it.

  10. thanks for writing the above, Dr Mike. People really think that seeing someone immediately will solve the problem. In my specialty, I have so many PCPs/Fam Docs/NPs think they can treat the problems, more often just complicate it with reckless prescribing, then literally dump it on me to “fix it”. Yeah, thanks to all for acting like you are specialists, until you realize that is why we have specialists.

  11. The time is past to consider revamping the education of an MD or DO without also rethinking the training of NPs,PAs, and even other allied health professionals. It seems like there should be more thought put into how these professionals are going to interact, and that should be part of the training.
    It is not currently clear what the role of primary care physicians will be in the next 10 to 20 years, but it is looking more and more like someone who wants to do primary care would be much better off financially going the NP route (but it is scary to think about what things are going to be like when the new breed of experience-less NPs hit the market in force – had one drop by for an interview some time back – didn’t know sqat, but she sure was proud of her 400 hours of family practice clinicals. 400 hours – less than 1/4 of a year. “Come back in a few years after you’ve made use of your RN to get some ER or Med/Surg or ICU experience”)

  12. I read this post and it doesn’t change my concerns with the direction of medicine. The best, brightest, committed, and caring people are not going to enter a profession that requires commitment and dedication when people are asking, if not demanding, for the practice of medicine to be continually dumbed down, if not alone for the sheer audacity of non physician providers being allowed more privileges and autonomy for care interventions they weren’t trained to provide.

    Who the hell wants to commit to at least 7 years of education after college and be treated like an assembly line worker, while still incurring a sizeable debt that will not be dismissed by the false promises of politicians? So many of the writers at sites like this I don’t think get it. As do a lot of the usual commenters here as well. If all of the involved parties that need to be participating and willing to make sacrifices/compromises actually do so, than maybe American health care has a chance to improve and be more cost efficient.

    Until then, we continue to listen, literally, to an adage of “words, not deeds are what define us”. Patients, providers, families and significant others, hospitals, Med Tech and pharmaceutical orgs, government and regulatory bodies, physician organizations, health care insurers, and any other major players I am forgetting here now, all need to realize the status quo is only the status woe.

    I would start with end of life care expenditures. The era of the alleged blank check is over, and anyone who argues otherwise is not paying any of those bills, I guarantee that is a fact!!

    By the way, my condolences to you Mr G for your mother’s passing.

  13. In lots of these discussions people forget about nights and weekends. Many of our sickest patients arrive at those times. At smaller hospitals, you may have just one or two docs in the whole hospital at those times. If you want to specialize early, you may also want to specialize for small vs large hospital. Alternatively, perhaps you could have different practice standards for different times and places.


  14. Regarding healthcare costs, I think there is a huge difference between the U.S. and other countries in both patient expectations and the litigation environment. The medical specialty societies have no choice but to factor these realities into their thinking as they develop the standard of care in each specialty and each course of treatment within them. The end result is more testing to develop a definitive diagnosis and much more intensive care at the end of life in the absence of a living will or advance directive to the contrary. I don’t think that shortening the time it takes to train a doctor by a year or two or even making medical school tuition free to the enrollee will have much impact on healthcare costs as long as our patient expectations and litigation environment remain unchanged.

  15. Addendum — A word about costs.

    Having worked in a healthcare system and around long-term care environments in my post-retirement life I am aware of two, perhaps three layers of intensity of care. They are (1) Monday through Friday, (2) Nights and (3) Weekends. The current system already has a built-in triage of care based on these three layers. (And I already described a few of the alternatives which are not likely included in most statistics measuring the costs of medical care.)

    And before any patient gets into the system they will first be handled (whatever that may mean) by family, friends, strangers at the scene of an accident or first responders who may or may not have any training. So coupling efficacy with costs and training strike me as disingenuous. Margalit is correct. If other developed countries can do it better at lower costs I see no reason why the US cannot do as well.

  16. This is among the smartest posts and comments threads the Health Care Blog has put up for months. As I read Professor Fuchs’ observations and suggestions it struck me as a case of casting pearls before swine. But when the comments came I was quick to congratulate myself for not saying so. The comments are just as insightful. I like the “pit crew” and “cowboy” analogies. And Ms. GA’s example of Russian “engineers” drives home an important point.

    My career in the food business started with fancy foods, imported cheeses and wines, but after a short stint in fast food was spent mostly in a Southern cafeteria chain. As in the case of aeronautical engineering I became aware of the many gradations of experience and formal training on the landscape.

    Newcomers from what they called a “culinary arts” training program often scrubbed out because they didn’t understand that cooking is mainly two parts — set-up and clean-up,– and actual cooking was only something that happened in the background as those two vital parts were taking most of their time and energy. All those romantic images of a smiling cook (chef, grandma, baker or good-looking youngster in uniform) looking proudly at a photo-shopped version of an appetizing creation vanished like a cloud of steam as they came to realize there is a helluva a lot of very UNrewarding and time-consuming work that never shows in those magazines and videos.

    Most of my staff were like the Soviet-era “engineers.” My chef, head baker or lead cook might have crashed and burned in an upscale hospitality environment but they were irreplaceable in my operation because, like those pit crews, they knew their jobs and made them look easy. (Which brings up another point not mentioned above, that a lot of jobs that are totally essential and damn hard are often taken for granted and undervalued because too many observers are quick to say “anyone can do that.”)

    Having said all that, my take-away from this discussion is that there are too few doctors and the career path leading to the top tiers of the profession, whether specialty, generalist or teaching, has too few side-tracks for those who for whatever reason might serve essential roles that may never result in a six-figure income but are socially respected and professionally appreciated.

    I can tell you that in the metro-Atlanta area, in the shadow of Life University (formerly Life Chiropractic College) I am aware of an endless number of chiropractic and alternative medicine “clinics” and “providers” operating outside what most formally trained physicians would call real medical practice. Many now compete for what are still relatively modest insurance reimbursements. And there is often a “real” doctor or two on staff who can write prescriptions. It may be a cottage industry compared with the mammoth campus creations of mainstream medicine, but when we have conversations about uninsured people or that large and growing segment of the population outside the river of mainstream benefits this is a “market segment” often overlooked. And my layman’s impression is that many of these places are staffed and operated by castaways from the mainstream training track (the subject of this conversation). A way needs to be found to provide meaningful, respected and well-compensated roles for those who for whatever reason (raising a family, financial handicaps, and yes, IQ or physical limitations) do not matriculate the holy path to sainthood, but whose ambition, positive attitude and desire to be in the healing arts remain undamaged.

    Just the reflections of an old layman on a Saturday morning.

  17. Great comments, Margalit. And it is going to affect costs in a significant way: It will take more visits and more time and more tests to arrive at a diagnosis that can be endorsed to the overseers, treat the patient and document everything. Costs will go up.

  18. I would like to contribute a view from the other side of the fence. My degrees are in Aeronautical Engineering. I had to make the decision before I even applied to the University, because where I went to school, one applies to a specific department for admission. The same was true for medical school and law school. Granted, the average student was at least 21, since there is a mandatory draft, but there was nothing wrong with deciding early. The vast majority graduated in their initially chosen field. But I think that this is as far as the comparison can go.

    A brand new engineering school graduate will overwhelmingly head out to become an employee of an existing company, and in my field, usually a very large corporation. There will be at least 20 years before he or she will reach a position where any decisions of consequence are required. No young engineer will ever be confronted at 2 a.m. with a large ailing aircraft that must be fixed immediately. No older and experienced engineer (or a team of engineers) will have to deal with that either. Yes, engineers who participate in building aircraft do make design decisions that can spell life or death, but these decisions are never made in real time (excluding Apollo 13 scenarios), and are all simulated, tested in wind-tunnels both as models and prototype, stress tested and flight tested, multiple times over a period of several years, before one human life is placed at risk. Doctors do not have such luxury.

    In the same country, some years ago, there was an influx of immigrants from the former Soviet Union, many of whom where engineers. There were fishing engineers, tractor engineers, road engineers, fuel engineers, etc., and most ended up in janitorial jobs. Why? Because they lacked the fundamentals – all those seemingly unnecessary general courses were never part of the super-specialized curriculum aimed at producing cheap resources for a particular piece of the puzzle.

    Finally, “pit-crew” vs. “cowboy” is a false dichotomy. The folks that work in pit-crews know all there is to know about their racer. The guy that screws on the back tire can screw on the front tire, fuel the car and most likely can do a myriad of other things to that car. Similarly, the legendary cowboy knew everything there is to know about his trade. Both are generalists and both do their work in teams. I don’t recall any examples of a lone cowboy driving thousands of cattle over hundreds of miles.

    It makes sense that you can shave a year from medical training by requiring early commitment from students. You may also be able to take off another year by requiring early specialization, and perhaps more if you train doctors on the job, as is done in most other professions. Of course, the underlying idea here is that the physicians rank and file need to be employees, and since they will be less educated, they should also be less influential (or cowboy-like).
    But is this really going to affect health care costs in any significant way? I’m not sure I understand how. And what would be the effects on quality, if any?
    Is how we educate physicians the major difference between this country and other developed countries where costs are lower and perhaps outcomes are better?

  19. This deserves a long response, but I am short on time, so a few observations.

    1) Pit crew concepts work during daylight hours at large hospitals. After hours, and at small hospitals, docs need to be much more self-sufficient. Breadth of training and knowledge becomes very important.

    2) My most recent hires are slow and need significant mentoring. The decreased experience from reduced hours in training really shows. From my limited experience with European docs, I think what really happens is that new docs who have spent less time training often are mentored in or allowed to gain experience before taking on a full range of cases. IOW, you are simply deferring the last stage of learning until they are in practice.

    3) Figure out how to pay people to do this training. We can certainly train people faster, but it takes more time and effort on the part of the teachers. I have done clinical teaching for many years. I now dread having residents or students show up. The pace of work is faster and there is more to do with each patient. It slows me down when I have teaching responsibilities. It turns my normal 11-12 hour work day to 12-13 hours.


  20. Professor Fuchs, I read your article with interest, and as a physician, I am very concerned where our current health care system is going. I do believe that complete transparency is a key to any chance of making the system better. I further believe that re-establishing the patient-physician relationship as a centerpiece of medical care, rather than hospitals or technology, is crucial to making the system work, meaning specifically that the influence of hospitals, drug companies, medical device manufacturers, the government, and insurance have to mitigated. The medical education system is costly, and that is also going to be a big problem to address in the future. Doctors are already incentivized to pick specialities that have better salaries, and will continue to do so in the future unless medical education cost is addressed. I think eventually you will have a brain-drain, so to speak, of physicians, as people will go into other things that have less upfront cost and less back-end pressure. Unfortunately, we may have more wall street bankers as a result, rather than doctors and scientists and economists. You article is so dense, and there are just so many things to address, but as I see it, the main problems which most people simply don’t address is: 1. The current health care system does not provide healthcare but access to technology. 2. Most of it is questionable and does not focus on prevention but rescue care which is expensive and profitable. 3. True transparency of things like cost and incentives is not present in the system, and really, is a deceptive as times. Finally, in regards to medical education, why aren’t doctors taught how to open and run their business and provide the best product they can, like those in culinary school? For a 250,000 investment (in many cases) wouldn’t that be fair?