As I have gone through medical school, I have often asked a simple question: why? This question has led me to a deeper understanding of medicine and caused me to ask if things are the best they can be. Medicine has taught me that there is no one-size-fits-all model for educating patients, and I believe this also applies to students. Medical schools should more widely consider adopting a three-year option for students regardless of their specialty of interest. These are my opinions as a medical student and are meant to be a starting point for discussion, not the absolute truth on these matters.
My first point is that this is not a new idea. The president of the AAMC in 1990 said: “the present fourth year … turns out to be nothing more than a chance to travel about the country or engage in audition clerkships” (a sentiment that started my thinking about this topic). Two medical schools in Canada have had a three-year track for over 40 years, and many U.S. medical schools had three-year programs in the ‘70s and ‘80s that showed these students performed just as well clinically as their traditional four-year counterparts. The Consortium of Accelerated Medical Pathway Program (CAMPP), founded in 2015, includes all medical schools in the U.S. and Canada that offers a three-year track and currently has 22 member schools. With few exceptions, the fast tracks are geared towards students pursuing primary care and guarantee a match to their residency program. These programs are rightfully designed to help to close the gap on the shortage of clinicians (especially in primary care) we are going to see in the coming years.
Second, what is the role of a medical student as part of the team? Typically, the clinical medical student is the first person to talk to a patient and should be able to come up with a basic plan. When they forget or do not know something, the resident should help them along in learning the usual workup for that condition. The resident must speak to the patient and trust, but verify, what they were told. In this sense, I believe the role of the intern to be ideologically the same as the medical student. In addition, as students progress to their fourth year, they’re called sub-interns. Many of my mentors have said that the medical student’s goal should be to make the interns wonder why they came to work that day. Thus, the logical progression after the third year is to become a functioning intern.
My third point concerns money and time. Unless otherwise indicated, all of the following figures used are adjusted for inflation. The average clinician salary in 1975 was $262,000, and the closest date for medical school debt I found was in 1978 at $53,600. Compare that number to today, when the average clinician salary is $383,340, but the average student debt is $200,000 (including both public and private). Seen a different way: the student debt total was 20% of the clinician yearly income in the 1970s and 52% today. The value in looking at it this way is to show that clinician compensation has not kept up with student debt, likely due to a combination of many things, including the cost of living and tuition/fee increases. It is also worth discussing racial disparities in student debt. The AAMC’s Clinician Education Debt pamphlet clearly shows that racial disparities exist in terms of indebtedness of medical students favoring those well represented in medicine. There are studies that suggest that the extra year of salary, plus the savings from subtracting a year of tuition, total $250,000 across a lifetime. Further, significant savings can be generated by the removal of application and interview expenses (because students are guaranteed residency slots upon acceptance), which many students take out extra loans to afford.
Time is clearly on the mind of anyone considering or attending medical school. Residency and fellowship can add eight years on top of eight years of school. The traditional student will spend at least their 20s in school and training. It should be noted that the current format of four years of medical school was instituted in 1910 when that was the primary training that clinicians received because residency and advanced training were hard to come by. This meant that their training in medicine was four years — not seven, as is the minimum today. Another time-saving reason is to help patients by allowing clinicians to enter the workforce at a higher rate.
So how can we move this discussion forward, and what could the future of medical education look like? NYU has a program that, I believe, can lead as the national model for adopting a three-year option. The options to enter their accelerated program are summed up as follows:
1) Apply directly to the program when applying to medical school.
2) Matriculated students can opt in after acceptance anytime before the traditional MS2 year ends.
3) Those in the MD/PhD program can apply after completing their PhD. (It is not feasible to ensure every student a residency spot if this is applied on a broad scale. I think these students should be able to try to find the location they feel will be the best fit for them as traditional students do.)
This is a topic I think deserves more serious discussion among all medical school deans and should begin to play a larger role for students applying to medical school.
What are your thoughts concerning three-year medical school tracks? Share your opinions with your colleagues below.
Connor Breinholt is a current third-year medical student at the University of Texas Health - San Antonio. He plans to pursue general surgery.