When I was a member of the medical school faculty, my impressions of medical education at Hopkins were drawn exclusively from the four pre-M.D. years, plus postgraduate medical education. Now, as a university president, I contend with the rising costs of undergraduate college education on a nearly daily basis. This change in perspective has given me something of an outsider's-perhaps biased-view of medical education.
Standing on the other side watching undergraduates pursue a premedical curriculum, I have been formulating some thoughts about where we're at and what changes need to take place. I offer these opinions to my medical faculty colleagues with the caveat that they are purely subjective, unsubstantiated, and "from the gut" observations.
At the most fundamental level, the problem is all about money. Rising tuition, more restrictive loans and longer postgraduate training programs reduce the number of years in which a fully trained doctor can earn income, while increasing the burden of debt students must bear. The net effect is to lower the economic return on investment for a medical education compared to other professions. More and more medical students are forced to select their medical specialty guided strongly by economic factors. And yet, our education system is going along as if nothing had changed.
Consider:
- Prospective medical students are encouraged after four years in college to spend one or two years, sometimes more, doing "something else" before applying to medical school. In some cases, this provides a beneficial experience for the student, but for many, it simply lengthens the time before the student can enter the workforce and recoup the investment in her or his education.
- Considerable overlap of medical school basic science with undergraduate biological sciences exists for many students; such duplication is costly and inefficient.
- The medical school preclinical curriculum is overburdened with basic science courses, many of which will not prove to be beneficial to the large fraction of medical students who become practicing physicians.
- On the other hand, there is a paucity of courses that teach skills and content that may be extremely useful to doctors in the practice of medicine-such as ethics, public health, economics of medical practice, issues of patient safety, treatment protocols, communicating with patients, etc.
Some bright students have figured out how to "'beat the clock" by using AP courses and increased units per semester to graduate from college in three years rather than four. Such behavior, although perhaps not wise in terms of overall educational experience, offers tremendous economic leverage by reducing both cost and debt, thereby improving the return on investment.
These observations are not meant to be a broadside at college, medical school or postgraduate programs and administrators. Rather, I'd emphasize that no one, in my view, appears to be taking a holistic approach to training doctors: i.e., how can we train the best doctors in the shortest time from high school to medical practice for the lowest net cost? Since every step of the educational process is subsidized (that is, the cost of providing the education is far greater than the tuition charged), this is in fact a social problem as much as it is an individual one for future physicians.
I believe there are significant savings to be had in how we educate doctors, without imperiling quality. If we start from this assumption, I postulate that we can take several years off the training period and reduce by $100,000 or more the net investment needed to fully train each physician.
