This blog is a special contribution by a guest writer.
The California Future Health Workforce Commission (CFHWC) published a report in February of 2019 entitled “Meeting the Demand for Health” outlining 27 recommendations for building the health workforce of the future.1 The Commission predicted that over the next decade there will be 10% fewer primary care clinicians than the number needed to provide care for Californians.1 According to the US Census Bureau, California (CA) had an estimated population of about 40 million people as of July 1, 2018.2 Based on this data (without any increases in population), 4 million people will be without a primary care provider (PCP) by 2029. The average time it takes to train one physician for his/her career is 10-18 years. According to the CFHWC, California is projected to have a shortage of 4,103 primary care clinicians in 2030.1 If it takes at minimum an average of 10 years to train one physician, it will take on average 41,000 person-years to train the physicians required to close this gap in CA alone.
In order to prepare more physicians to address the projected provider deficit, the current medical education system must provide education in a more efficient and effective manner, reducing the number of years it takes to train physicians without compromising the quality of their training. CFHWC recently published some important ideas, including recruitment of college students from underrepresented areas and scholarship funding to support graduates serving in underserved areas.1 In addition to the CFHWC’s recommendations, the American College of Surgeons published an article in June of 2019 entitled “New Pathways for Medical Student Education Address Concerns of Both Students and Educators” which discusses recent changes made by well-respected medical schools including three year pathways of medical education and early integration of clinical experiences.3 While these recommendations are important, they will not be enough to train physicians in a timely enough manner to solve the current provider crisis. The focus of this blog will be to discuss disruptive changes required by accredited medical schools to shorten the duration of medical education. This shorter duration will allow medical schools to solve the current provider deficit by training more physicians who are better prepared for the challenges faced by those practicing in our current “on demand” healthcare system.
For more than 100 years, US physicians have been trained by the same four year pattern recommended by the Flexner Report published in 1910. Traditional medical school consists of two years of basic science teaching followed by two years of clinical training called “rotations” or “clerkships." During clerkships, students spend time caring for patients in specific medical disciplines. Dr. Clayton Christensen, a Harvard Business Professor best known for his theory of “disruptive innovation,” published a book in 2009 called The Innovator’s Prescription.4 A chapter of this book is dedicated to the future of medical education. Dr. Christensen expresses concern that it takes much longer to educate tomorrow’s doctors when compared to other careers and that despite being well trained, graduates are often unable to practice profitably when finished. After discussing his concerns, he describes how to create a sustainable medical curriculum capable of training better doctors with less student-to-student variability in a shorter, more cost efficient way.
The first recommendation Dr. Christensen makes is the integration of basic sciences and clinical education. Paralleling these two necessary aspects of medical education will cement basic science and clinical knowledge for learners in a usable clinical format, improving retention and recall which in turn will result in improved efficiency and cost effectiveness. This improved efficiency would decrease the overall duration of medical school as well, providing skilled physicians in a timelier manner.
In order to understand the importance of integrating the two main components of medical education, the basic sciences and the clinical sciences, one must understand the chronology of medical school. Starting year one, a large bolus of students arrives together, attending the same basic science classes for two years. Once the basic sciences are completed these students begin their clinical clerkships. The problem with this structure is that the basic science and clinical rotations are temporally spaced by two years, leading to information that is often forgotten or not regularly used in clinical practice once clerkships start. In addition, due to the volume of students entering clinical rotations at the same time, they cannot all start with the same clerkship; thus, clerkships are completed by each student in a different sequential order, leading to an immense number of learning pathways. The time gap between basic and clinical sciences and the substantial number of learning pathways that occur during clinical rotations cause inefficiency and re-teaching as each student arrives at a given clerkship with a different combination of knowledge, training experiences, and skills. If the curricular redundancy, re-teaching and overall inefficiency could be improved, the duration of medical school could possibly be decreased to about two and a half years.
Dr. Christensen suggests that accredited medical schools should begin to integrate basic and clinical sciences differently within their current systems by matriculating smaller groups of trainees throughout the year in a “drip” system rather than the current “bolus” system.4 This “drip” system will allow students to rotate from one clerkship (which integrates some of the basic sciences) to the next in the exact same sequential order, decreasing variability of training experiences and skills and allowing for a more efficient, cost effective and predictable teaching/learning outcome. This predictability will allow for less redundancy in teaching and allow educators and administrators to shorten the duration of the whole educational experience. Of note, this change from “bolus” system to “drip system” in medical school matriculation will also require logistical changes to graduation and the start of residency since students will finish throughout the year rather than altogether at the end of a typical academic year. This “drip” system of matriculation will allow for medical educators to offer a more controlled learning environment to smaller groups of students, helping students get the “right information at the right time” in a shorter period of time.4
In addition to integrating the basic and clinical sciences in a “drip” matriculation system, another critical step that Dr. Christensen recommends is to change the current learning model from a fixed time, variable learning model to a variable time, fixed learning model.4 Currently, medical schools operate on a fixed time, variable learning model in which the time students spend learning is fixed while the result of the training is variable and unpredictable. As mentioned earlier, the unpredictability of the whole medical education experience can lead to higher costs and inefficiency, requiring repetition and re-teaching as some students grasp topics quicker than others. A variable time, fixed learning environment would allow medical students and educators variable time to master the knowledge and skills required of one clerkship prior to moving onto the next. While this may seem like an administrative nightmare, this author believes that this model will actually provide a more efficient educational experience. Students who grasp topics more quickly than others can graduate at a quicker pace, providing more providers in a shorter period of time. This system will also allow medical educators to focus on those who are struggling, preventing drop out, while still graduating knowledgeable providers prepared for the current healthcare environment. In addition, this variable time, fixed learning model will allow for more predictable and measurable outcomes. This predictability will allow educators to make changes to the curriculum on a “point of care” level, actually improving efficiency, lowering costs, encouraging collaboration.
In our current “on-demand,” “at-the-touch-of-button” society, high quality, timely, and patient-centered healthcare is needed more than ever. Our current medical education system is not projected to meet the needs of a growing population. Ideas such as the integration of basic and clinical sciences, the implementation of a drip system of matriculation, and the use of a variable time, fixed learning model are just a few changes suggested to help shorten the duration of the medical educational training and meet the demand for healthcare providers. These changes, if implemented well, will aid the current medical education system in its desire to create the quantity of patient-centered, high quality, and cost effective physicians required for the healthcare of the future in a timelier manner, helping to address the current provider shortage.
Dr. Zachary Carter is a 3rd year Physical Medicine and Rehabilitation resident at Loma Linda University Health. He graduated from The George Washington University School of Medicine and Health Sciences with an emphasis in health policy. In addition to caring for a diverse group of patients, he is passionate about health care systems management and the improvement of the healthcare system as a whole.
- Meeting the Demand for Health: Final Report of the California Future Health Workforce Commission. (2019) Retrieved July 21, 2019 from https://futurehealthworkforce.org/our-work/finalreport/
- "United States Census Bureau Quick Facts California." (2018) Retrieved July 21, 2019, from https://www.census.gov/quickfacts/CA.
- Peregrin, T. (2019) New Pathways for medical student education address concerns of both students and educators. Bulletin of the American College of Surgeons
- Christensen, Clayton M., Jerome H. Grossman M.D., and Jason Hwang M.D. The Innovator's Prescription: A Disruptive Solution for Health Care. McGraw-Hill, 2009.