Should It Really Take 14 Years to Become a Doctor?

Tuesday, March 18th, 2014

Should it really take 14 years to become a doctor? Brian Palmer reminds us how this all got started:

An American physician spends an average of 14 years training for the job: four years of college, four years of medical school, and residencies and fellowships that last between three and eight years. This medical education system wasn’t handed down to us by God or Galen—it was the result of a reform movement that began in the late 19th century and was largely finished more than 100 years ago. That was the last time we seriously considered the structure of medical education in the United States.

The circumstances were vastly different at that time. Until the Civil War, private, for-profit medical schools with virtually no admissions requirements subjected farm boys to two four-month sessions of lectures and sent them off to treat the sick. (The second session was an exact duplicate of the first.) The system produced too many doctors with not enough training. Abraham Flexner, the education reformer who wrote an influential report on medical education in 1910, put a fine point on the problem: “There has been an enormous over-production of uneducated and ill trained medical practitioners,” he wrote. (Emphasis added.) “Taking the United States as a whole, physicians are four or five times as numerous in proportion to population as in older countries like Germany.”

In other words, our current medical education system was originally designed to reduce the total number of people entering the profession. The academic medical schools that sprang up around the country—such as the Johns Hopkins Hospital in 1889—made college education a prerequisite. Medical school expanded from eight months to three years and solidified at four years in the 1890s. Postgraduate training programs were implemented, beginning with a one-year internship. These were brilliant reforms at the time.

Over the past century, there have been additions to, but few subtractions from, the training process. Residency and fellowship programs became longer and longer … and longer. The path to some specialties is now almost comically arduous. Many hand surgeons, for example, complete five years in general surgery, followed by three years in plastic surgery, followed by another year of specialized hand surgery training. To be a competitive candidate for a hand surgery fellowship, it’s also strongly recommended to spend two additional years on research at some point during the process.

One crazy idea comes from the outcomes movement:

American medical schools and residency programs have traditionally relied on the “tea steeping” method: They expose students to information for a prescribed amount of time, and assume they’re ready at the end of it. Years can be added if a student demonstrates gross incompetence in exams, but there’s no opportunity for exceptional students to accelerate the process. Offering that chance makes educators uncomfortable—both because it relies heavily on imperfect examinations and because it partially undermines the traditional process—but it’s time to experiment.

“Experiment” is the key word. The fundamental problem here is that the argument between traditionalists and reformers is essentially theoretical—we are in an evidence vacuum. It’s ironic, because in virtually every other aspect of medicine, tradition and intuition were discarded decades ago. Researchers rigorously test what is the best moment to start someone infected with HIV on antiretrovirals or a patient with high cholesterol on statins. But doctors have very rarely examined their own training. When Emanuel and Fuchs published their proposal two years ago, they could find just a single study comparing the competence of physicians from the traditional four-plus-four medical education system with that of doctors from shortened programs.

There is no reason not to do this important research.


  1. Barnabas says:

    I went through all those years of training. All of it was useful and probably necessary with the exception of 4 years of useless undergraduate work and a year of research. Foreign medical grads often go straight into a 7 year medical school program. Those programs are typically subsidized so no huge debt load.

  2. Barnabas says:

    In medical training there is really no substitute for seeing many many cases. Reading, good professors, more responsibility put on the resident all help but typically more years of training and more hours worked per week will result in a better doctor in the long run.

  3. Toddy Cat says:

    I know that we trained a lot of pretty good doctors on pretty short notice in WWII. Obviously, medicine is a lot more complicated these days, and, as Barnabas says, there’s no substitute for experience, but I’d be shocked if we couldn’t streamline the process by at least a couple of years.

  4. Al Fin says:

    Agree with Barnabas that many, many cases must be seen and worked with to build expertise. Also, undergraduate training is not important enough to require 4 years.

    But this will become a moot point, as more and more physicians will be replaced by PAs and NPs in the US. Not to mention other paramedical and non-medical occupations, gradually but inevitably infringing on the medical profession.

    The economics of the “Obamacare — ageing population confluence” makes drastic changes in the profession unavoidable. Countries should not elect clownish ideologues as presidents, senators, and congressmen.

  5. Zhai2Nan2 says:

    Don’t forget that medical students are routinely forced to make life-or-death decisions while working under severe sleep deficit!

    Take young people, allow them about four hours of sleep, and put them in charge of people’s health! Brilliant!

  6. Dan Kurt says:

    Showed this to my sister, an internist, a retired medical school professor, a former director of an internal medicine residency program, a seventeen year member of a medical school admissions committee, and who also is retired from executive position in giant HMO who was directly concerned with quality control of the practice patterns of the HMO’s physicians and nurse practitioners.

    Her response to the article: when it all is reduced to what is important in medical education there are three factors that limit the supply of good MDs: 1) IQ of candidates; 2) conscientiousness of candidates, and 3) length of hands on experience under supervision of candidates during training. Good, competent MDs will always be in short supply. Four years of college helps mature candidates as well as prove competence and conscientiousness if done in a hard science. Residencies should be incredibly hard in content and time spent with patients especially during the first two years and government edicts on how many hours a resident can work limit drastically the learning experience.

    She scoffed at measures to shorten training time and at the same time increase quality. She also said that affirmative action has been counterproductive as to quality of output. She ended with a sarcastic remark that it is stupid to assume that those in medical education have ignored the problem of constrained supply of MDs. She repeated the three points listed above. She said that if one wanted excellent or even good MDs it takes TIME. Rare students may proceed faster but even those super bright need the hands on experience that can not be shortened. The experience in WW2 was that those fast tracked MDs got their experience as if from a fire hose under combat conditions with the wounded and sick from the battlefield, something not remotely possible in peacetime.

    Dan Kurt

  7. Barnabas says:

    Many medical schools now graduate more female students than male. Experience tells us that many of those female doctors will choose to work less hours and see less patients than male doctors, they will take maternity leave, and some will marry and leave the field all together. That doesn’t bode well for supply of MDs.

  8. Al Fin says:

    Females got in on the affirmative action bandwagon just like blacks and “hispanics,” whatever they are. Females do not intrinsically have meaningfully lower IQ or conscientiousness, so affirmative action in female medical school admissions is not necessarily dangerous to patients on the surface level.

    Barnabas points out that more females work shorter hours as physicians, and can leave the field for years or decades at a time to raise children. This can put a strain on those who keep working, in particular areas, but that problem is nothing compared to what Obamacare is bringing to the States.

    Affirmative action (preferential treatment) in medical admissions for groups with lower average IQ and executive function, on the other hand, is potentially extremely hazardous to patients. I have personally had to clean up a number of messes caused by some of those. That problem is only going to get worse.

    As for Dan Kurt’s sister, we should respect her experience. At the same time, remember Daniel Kahneman’s research on expertise and its limitations. If an expert says something is possible, it probably is. If an expert says something is impossible, then the thing is most likely still possible. Experts become boxed in by their experience at the same time that most of what they do is facilitated by their experience.

    You don’t know what you don’t know. And besides, everything you think you know just ain’t so.

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