Medical Training Was Designed to Reduce the Number of Doctors

Yay, only 10 more years to go!

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We need more doctors. On a global scale, the shortage is staggering: The World Health Organization says we need 15 percent more doctors. In the United States, the American Association of Medical Colleges estimates the current deficit at almost 60,000 and forecasts a worrisome 130,600-doctor shortfall by 2025. There’s one simple solution: We have to consider ways to manufacture doctors faster and cheaper.

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 19^th 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.

The current system has costs beyond making doctors expensive and rare. The long process doesn’t just weed out the incompetent and the lazy from the potential pool of physicians—it deters students who can’t pay for so many years of education or who need to make money quickly to support their families. That introduces a significant class bias into the physician population, depriving a large proportion of the population of doctors who understand their background, values, and challenges.

One solution is to simply lop off a few years from the process. Writing in the Journal of the American Medical Association in 2012, bioethicist Ezekiel Emanuel (one of those Emanuels) and economist Victor Fuchs recommended shortening each stage by about 30 percent. Four years of premedical training shouldn’t be a requirement for those who don’t want it or can’t afford it, they argued. The fourth year of medical school is largely a breeze, and a few progressive medical schools are now offering three-year programs to reflect that reality.