Decoding Health Care

Part 26: Medical Education Part 1

When I was a child I knew I wanted to be a doctor when I grew up. I am not sure why. There were no doctors in my family. My father was an insurance salesman and my mother was a stay at home mom raising four kids. Only one person in my family had graduated from college, my uncle who had a PhD in Latin and Greek. But I was a good student and I liked science, and physicians were highly respected members of the community. Most of what I knew about being a doctor came from television. Nonetheless I made a good decision. I had a great career. And I even loved medical school as well as post graduate training. I sometimes wonder how many of today’s physicians (or physicians in training) can say that. Why?

American medical education has been basically the same for the last 100 years. In 1910, Abraham Flexner, supported by the Carnegie Foundation and with the backing of the American Medical Association’s Council on Medical Education (CME), published an exhaustive report on the state of medical education (1910: The Year American Medicine Changed Forever | RealClearScience). Flexner was not a physician or a medical educator, but had earned his stripes doing a similar analysis of American colleges. And he did a very thorough job looking at medical schools. He criss-crossed the country visiting a huge number of schools, cataloguing their strengths (and mostly weaknesses). His criticism was unflinching. What he found was that many medical schools were proprietary, that the curriculum was unscientific and often not evidence based (even fringe), and that the educational process was nonstandardized. Medical schools at the time were producing way too many unqualified doctors. And because medical education was not tied in any meaningful way to medical licensure there was no accountability.

Prior to the Flexner report the AMA knew there was a problem. In 1904, even before Flexner, the AMA’s CME defined the appropriate “pre-medical” education and also established the basic architecture of medical education that survives to this day, namely two years of basic science education followed by two years of clinical training. Flexner expanded on this. He wanted medicine to be a scientific discipline. He wanted standardization. He wanted professionalism. And he wanted state medical licensure to be the mechanism to quality control “the product”. Flexner’s report was embraced.

In order for Flexner’s vision to become reality several things needed to happen. A large number of medical schools needed to be shut down, especially ones that were proprietary or taught alternative, “fringe” medicine. Medical schools became affiliated with universities. Premedical prerequisites were standardized as was medical school curriculum including the clinical, hospital based curriculum. Medical schools hired full time faculty. And state medical boards became critical gatekeepers.

Flexner’s report transformed medical education. But it had some huge negative consequences. The two most important were that he held and promoted profoundly racist and sexist views. He did not think Blacks or women should be physicians. And as the number of medical schools contracted, medical schools that accepted and trained Blacks and women largely disappeared. To this day we continue to suffer from Flexner’s prejudice.

When I was in college and medical school, those rules established by Flexner were deeply entrenched. As a student in the late 1970s, premedical education was extremely rigorous. The curriculum appeared to promote competition, and act as a way to “weed out” the students who couldn’t cut the academic mustard. Organic chemistry was the grim reaper. Poor grades discouraged and even eliminated many aspiring physicians.

Medical school admission is still highly competitive (Medical School Acceptance Rates by Race, Major, MCAT/GPA | MedEdits). When I applied, about 35% of applicants were accepted, but many students did not apply because they didn’t think they had a chance. Today, the acceptance rate is just above 40%. Again, these numbers are a little deceiving. The most highly competitive schools, like Stanford or Harvard have acceptance rates much less than 5%. The number of women accepted has increased tremendously (currently half of medical school students are women). The percent of medical students who are white has dropped but mostly because of increased Asian acceptances. The percent of matriculating students who are Black males has not changed much in the last 40 years (3%). The absolute number of medical school applications as well as medical students has increased a lot, reflecting a number of new medical schools and increased role of osteopathic schools in medical education (osteopaths make up 25% of medical students, and the number has increased 77% over the last decade).

Presumably the rigorous premedical curriculum and competitive admissions process serves a purpose: to guarantee that students who start medical school will finish medical school and become doctors. 95% percent do. But it ain’t easy, to say the least.

The first two years of medical school are like drinking from a fire hose. The volume of material and the pace are breathtaking. Given how hard medical students need to work it is amazing that suicide isn’t a bigger problem. But depression and anxiety are common, affecting up to a third of medical students (Mental health trends among medical students - PMC). It’s just that there is so much material, and the amount increases every year. Although there has been a lot of focus over the years on anatomy (and the first time students experience a cadaver), in fact the best paradigm is probably biochemistry with its unending series of metabolic pathways. The challenge for medical students is connecting all of that memorization with the ultimate goal of taking care of patients. That link can seem tenuous at best.

I did very well in the first two years of medical school. I was blessed with an incredible memory and enviable discipline. I have always thought that the way to look at the first two years of medical school was that it wasn’t so much the facts you learned but rather how you learned. Medical education was an iterative process, founded on a strong scientific basis upon which clinical teachings were dependent. It was hard because medicine was hard. To be good you needed to put in the time, and you needed to do that over and over again. Life long learning was required, and the habits established in medical school were critical to being a good doctor. Lots of people disagree with me, and I myself am having second thoughts.

When I was a medical student we had minimal patient contact until the third year. The thinking was that we just were not ready for it. My classmates HATED that they had no patient interactions. They felt that by engaging patients they would feel that all that hard basic science work was going to ultimately be justified. As time has gone on, the medical education establishment has come to that opinion as well.

My daughter is a third year medical student and her curriculum reflects current thinking on the best way to educate physicians. It is quite different from the curriculum I survived (the “old style”). During her pre-clinical training she has had a sequence of “system” modules in which a specific body system (say cardiovascular) is taught in a comprehensive fashion. Those modules include anatomy, histology, pathophysiology and pharmacology. This is in contrast to the “old style” in which first year students has a year of anatomy, marching through the various body parts. Clinical exposure is sprinkled in including physical diagnosis. This seems a fairly logical way to study health and disease. But it has some shortcomings. There is no anatomy for psychiatry. And cancer of the colon has more in common with cancer of the breast than with other digestive system diseases. Nonetheless, my daughter really liked it.

There is one huge problem though. There is still just too much information. And a lot of it isn’t relevant. Plus there is stuff not covered that is super important. And most problematic of all is that we continue to test knowledge (inferring competence) in the same way we always have. Let me explain.

We are fortunate to live near my daughter’s medical school and we can visit on weekends or during her school breaks. She is always studying. Often she is working on practice questions that are typical of those she will experience on her exams. She takes great delight in asking my wife and I those very questions (since we are both board certified physicians with many years of practice experience) and watching us get them wrong. It is sort of like dinner table Jeopardy (I know, what a bunch of nerds). We often do get those questions wrong. In my opinion, those questions are stupid (and not just because I get them wrong). They explore trivia. They are often written in a fashion designed to deceive. Just like when I was in medical school.

Why? Well part of the problem is likely that old prejudices die hard. We think that by knowing those bits of trivia we have mastered the science of medicine and will be good doctors. A much bigger problem is that the path to medical licensure requires passing exams with exactly those kinds of questions. So medical schools are teaching to the test.

When I was in medical school, the testing program was run by the National Board of Medical Examiners (NBME); currently, the program is run by the NBME and Federation of State Medical Boards and is called the US Medical Licensing Exam (https://www.usmle.org/). It consists of three parts (called Step 1,2 and 3) that test knowledge of scientific principles that are the underpinning of medical science as well as the application of this knowledge to provide patient care. The tests are grueling. They are closed book. Steps 1 and 2 are whole day affairs, taken during medical school, and STEP 3 is administered over 2 days and taken during the first year of residency. The tests are expensive, costing close to $700 each and are given at test centers.

My daughter has completed STEP 1. It is pass/fail and she passed. Her school gave her and her classmates a month off to study. As with most standardized tests, there are ample test prep tools available that include “sample” questions. To my eye, these questions were the same stupid questions posed in her medical school classes. But you NEED to pass the exam to get a license so you suck it up and do what you need to do.

Why am I so critical? Because it is impossible to know all of that trivia. Just carrying the Washington Manual in your pocket isn’t enough. Medical knowledge changes regularly. It is much more important to know what you do not know and where to find the answer, and answers are readily available for most of those questions. In fact, that answer may be as close as your cell phone. It is much more important to know what matters and what does not and how to put facts together. It is much more important to ask the right questions as opposed to pretending to know all the answers. Artificial intelligence, with its ability to collate and query vast amounts of knowledge is likely to make the fools errand of trivia memorization irrelevant. But AI is dependent on the quality of the data it has access to. I think we need to radically change how we teach medical students to be good doctors.

One of the consequences of being stuck in this trivia rut is that it takes time away from other things that medical students ought to be learning. How do you evaluate the medical literature? How is health care paid for and delivered? How do you deliver bad news to patients? How do use and electronic medical record? The other stuff you can look up.

Ezekiel Emanuel wrote a nice short piece expressing some of his opinions regarding medical education (Reforming American Medical Education - PMC). Among other things, he favors a contraction in some of the preclinical curriculum and an expansion in some practical subjects important to being a good doctor. He argues that the clinical part of medical education should move away from the hospital to the outpatient setting (where most care is delivered). Many of his proposals interestingly are in direct conflict with what Flexner proposed over 100 years ago. It is time for a change.

My daughter is an excellent medical student at the top of her class and she will be an excellent doctor. I am shamelessly proud of her. I think if you asked her she would tell you that she really likes medical school. Just like I did 40 years ago.

Medical education does not end when you graduate medical school. In my next post I will discuss post graduate training, how students choose a specialty and why primary care is in trouble, “alternative” medical careers that do not involve patient care, as well as continuing medical education.