Where medical education goes wrong

Despite recent efforts to modernize the MCAT, update the USMLE, and invigorate interdisciplinary health professional training, medical education remains a fortress of tradition and myth. Our assumptions about what it takes to prepare exemplary physicians remain largely unproven and idiosyncratic and our outcomes of medical practice, mediocre. It is time to truly reform medical education, beginning with our accrediting and testing bodies (testing drives the curriculum) and extending to our pipeline into medical school and to instructional design.

Just look at our hidebound requirements, consisting of such important subjects as organic chemistry and physics. The last time I used organic chemistry in the actual practice of medicine was … well, pretty much never. Yes, I can hear the chorus about how performance in organic chemistry is a litmus test of achievement on … well, standardized tests. And how scientific principles undergird our practice of medicine.

Poppycock, I say.

Put more emphasis on the social sciences
Medicine could be better served by a solid grounding in medical anthropology, medical sociology, and applied epidemiology. While it may be satisfying to understand the underpinnings of the treatment of diabetic ketoacidosis (although so many of our explanatory models eventually are proven wrong), far more medical mischief is caused by poor communication skills, ignorance of a patient’s culture and perspective, and the inability to apply even rudimentary statistical concepts. Surely performance in the social sciences could be used as an indicator of equal rigor—if the correct yardstick were used.

And therein lies the problem. We use MCATs and USMLE as the sum measure of performance, or assess success on the basis of admission to highly selective specialties (which use the same measures to winnow the applicants). Of course, there’s a correlation—and a tautological fallacy. What we really should be measuring is success as a physician, and until we have robust outcome data for sufficient populations of patients, we are simply deluding ourselves. Let’s stop publishing MCAT and GPA scores and fueling the US News and World Report ratings, and start choosing students who will make a real difference in our world.

Do away with one-size-fits-all training
Another ridiculous myth is that we must have 4 years of training to become physicians. For some, yes. But we really must measure competencies. I’ve known students who should be in medical school for 7 years, and a few who could finish in 2. The 4-year program, I believe, is more for convenience of planning than for educationally sound reasons.

And does anyone really believe that 4th-year auditions for residency are a highly important component of the training of competent physicians? Seeing many young doctors in training has convinced me that our measures of competence are rudimentary at best.

I also think we need to differentiate between students aspiring to be research scientists and those pursuing a clinical career. Much of what we stuff into the heads of our clinicians is useless at best, and harmful to many: lengthy differential diagnoses of obscure diseases that encourage over-testing, and training at quaternary centers that cater to the sickest patients with the most unusual diseases. Moreover, becoming a successful researcher requires a more robust grounding in one’s chosen field of science, if not via an MD-PhD, then at least through advanced training. So why don’t we own up to the fact that one size does not fit all?

Reconsider specialty choice
Finally, why is an open career choice considered a god-given right for our students? Does our country really need the droves of students attracted to emergency medicine, orthopedics, and anesthesia? Should our society be supporting the whims of every 20-something medical student? I think not. And why don’t we have a required service obligation for all new physicians—a year, say, for every year of training. Let’s start to fill our rural and urban areas with an expanded National Health Service Corps that guarantees a sustainable source of health care providers.

It is time to have a frank conversation about medical education. Not a 5-year study by an august group that shuffles the same tired assumptions. Not an advocacy effort that is preordained to recommend more of the same. Isn’t it time we begin to expose our tacit assumptions about medical education and plan for an evidence-based and socially informed set of policies and practices?

Despite recent efforts to modernize the MCAT, update the USMLE, and invigorate interdisciplinary health professional training, medical education remains a fortress of tradition and myth. Our assumptions about what it takes to prepare exemplary physicians remain largely unproven and idiosyncratic and our outcomes of medical practice, mediocre. It is time to truly reform medical education, beginning with our accrediting and testing bodies (testing drives the curriculum) and extending to our pipeline into medical school and to instructional design.

Just look at our hidebound requirements, consisting of such important subjects as organic chemistry and physics. The last time I used organic chemistry in the actual practice of medicine was … well, pretty much never. Yes, I can hear the chorus about how performance in organic chemistry is a litmus test of achievement on … well, standardized tests. And how scientific principles undergird our practice of medicine.

Poppycock, I say.

Put more emphasis on the social sciences
Medicine could be better served by a solid grounding in medical anthropology, medical sociology, and applied epidemiology. While it may be satisfying to understand the underpinnings of the treatment of diabetic ketoacidosis (although so many of our explanatory models eventually are proven wrong), far more medical mischief is caused by poor communication skills, ignorance of a patient’s culture and perspective, and the inability to apply even rudimentary statistical concepts. Surely performance in the social sciences could be used as an indicator of equal rigor—if the correct yardstick were used.

And therein lies the problem. We use MCATs and USMLE as the sum measure of performance, or assess success on the basis of admission to highly selective specialties (which use the same measures to winnow the applicants). Of course, there’s a correlation—and a tautological fallacy. What we really should be measuring is success as a physician, and until we have robust outcome data for sufficient populations of patients, we are simply deluding ourselves. Let’s stop publishing MCAT and GPA scores and fueling the US News and World Report ratings, and start choosing students who will make a real difference in our world.

Do away with one-size-fits-all training
Another ridiculous myth is that we must have 4 years of training to become physicians. For some, yes. But we really must measure competencies. I’ve known students who should be in medical school for 7 years, and a few who could finish in 2. The 4-year program, I believe, is more for convenience of planning than for educationally sound reasons.

And does anyone really believe that 4th-year auditions for residency are a highly important component of the training of competent physicians? Seeing many young doctors in training has convinced me that our measures of competence are rudimentary at best.

I also think we need to differentiate between students aspiring to be research scientists and those pursuing a clinical career. Much of what we stuff into the heads of our clinicians is useless at best, and harmful to many: lengthy differential diagnoses of obscure diseases that encourage over-testing, and training at quaternary centers that cater to the sickest patients with the most unusual diseases. Moreover, becoming a successful researcher requires a more robust grounding in one’s chosen field of science, if not via an MD-PhD, then at least through advanced training. So why don’t we own up to the fact that one size does not fit all?

Reconsider specialty choice
Finally, why is an open career choice considered a god-given right for our students? Does our country really need the droves of students attracted to emergency medicine, orthopedics, and anesthesia? Should our society be supporting the whims of every 20-something medical student? I think not. And why don’t we have a required service obligation for all new physicians—a year, say, for every year of training. Let’s start to fill our rural and urban areas with an expanded National Health Service Corps that guarantees a sustainable source of health care providers.

It is time to have a frank conversation about medical education. Not a 5-year study by an august group that shuffles the same tired assumptions. Not an advocacy effort that is preordained to recommend more of the same. Isn’t it time we begin to expose our tacit assumptions about medical education and plan for an evidence-based and socially informed set of policies and practices?

Despite recent efforts to modernize the MCAT, update the USMLE, and invigorate interdisciplinary health professional training, medical education remains a fortress of tradition and myth. Our assumptions about what it takes to prepare exemplary physicians remain largely unproven and idiosyncratic and our outcomes of medical practice, mediocre. It is time to truly reform medical education, beginning with our accrediting and testing bodies (testing drives the curriculum) and extending to our pipeline into medical school and to instructional design.

Just look at our hidebound requirements, consisting of such important subjects as organic chemistry and physics. The last time I used organic chemistry in the actual practice of medicine was … well, pretty much never. Yes, I can hear the chorus about how performance in organic chemistry is a litmus test of achievement on … well, standardized tests. And how scientific principles undergird our practice of medicine.

Poppycock, I say.

Put more emphasis on the social sciences
Medicine could be better served by a solid grounding in medical anthropology, medical sociology, and applied epidemiology. While it may be satisfying to understand the underpinnings of the treatment of diabetic ketoacidosis (although so many of our explanatory models eventually are proven wrong), far more medical mischief is caused by poor communication skills, ignorance of a patient’s culture and perspective, and the inability to apply even rudimentary statistical concepts. Surely performance in the social sciences could be used as an indicator of equal rigor—if the correct yardstick were used.

And therein lies the problem. We use MCATs and USMLE as the sum measure of performance, or assess success on the basis of admission to highly selective specialties (which use the same measures to winnow the applicants). Of course, there’s a correlation—and a tautological fallacy. What we really should be measuring is success as a physician, and until we have robust outcome data for sufficient populations of patients, we are simply deluding ourselves. Let’s stop publishing MCAT and GPA scores and fueling the US News and World Report ratings, and start choosing students who will make a real difference in our world.

Do away with one-size-fits-all training
Another ridiculous myth is that we must have 4 years of training to become physicians. For some, yes. But we really must measure competencies. I’ve known students who should be in medical school for 7 years, and a few who could finish in 2. The 4-year program, I believe, is more for convenience of planning than for educationally sound reasons.

And does anyone really believe that 4th-year auditions for residency are a highly important component of the training of competent physicians? Seeing many young doctors in training has convinced me that our measures of competence are rudimentary at best.

I also think we need to differentiate between students aspiring to be research scientists and those pursuing a clinical career. Much of what we stuff into the heads of our clinicians is useless at best, and harmful to many: lengthy differential diagnoses of obscure diseases that encourage over-testing, and training at quaternary centers that cater to the sickest patients with the most unusual diseases. Moreover, becoming a successful researcher requires a more robust grounding in one’s chosen field of science, if not via an MD-PhD, then at least through advanced training. So why don’t we own up to the fact that one size does not fit all?

Reconsider specialty choice
Finally, why is an open career choice considered a god-given right for our students? Does our country really need the droves of students attracted to emergency medicine, orthopedics, and anesthesia? Should our society be supporting the whims of every 20-something medical student? I think not. And why don’t we have a required service obligation for all new physicians—a year, say, for every year of training. Let’s start to fill our rural and urban areas with an expanded National Health Service Corps that guarantees a sustainable source of health care providers.

It is time to have a frank conversation about medical education. Not a 5-year study by an august group that shuffles the same tired assumptions. Not an advocacy effort that is preordained to recommend more of the same. Isn’t it time we begin to expose our tacit assumptions about medical education and plan for an evidence-based and socially informed set of policies and practices?