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Finding a faster route to practice from medical student to board certified physician.

Introduction

Are we forcing new physicians to endure too much clinical training before receiving a full license to practice medicine? In the 1970s, it was not uncommon for physicians to open up a practice after only three years of clinical time. Today's medical students average over five years of clinical education. If a 22 year old entering medical student decides to pursue a primary care field, the earliest age this student can expect to be fully licensed to practice medicine is 29. If the student decides to pursue a more specialized field, such as a seven year neurosurgery residency followed by a two year fellowship in endovascular surgical neuroradiology, then he can expect to obtain full practice rights at 35!

Students beginning to practice sooner will have less debt, and more years of life to earn revenue as a practicing physician. The long time period between entrance into medical school and full practice capability can make high amounts of student loan debt much more intimidating. In 2005, Osteopathic graduates reported average educational loan debt of $149,800 per person. (1) In a more recent American Association of Medical Colleges (AAMC) study, the average amount of student debt for the class of 2008 was $154,607. (2) Some argue that medical school tuition should be lowered, but one might be surprised to learn that decreases in tuition would do relatively little to affect medical student debt. (3) Shortening the time needed to obtain full practice rights has been shown to have the greatest impact.3 How can we amend medical education to allow students to obtain full practice rights earlier?

There are only two ways to shorten the time it takes currently matriculating medical students to obtain a license to practice: 1) decrease the time spent in residency, and/or 2) decrease the time spent in medical school. Other options, such as combining undergraduate college education with medical school, are inherently limited in scale, and will not be discussed. We can either develop accelerated residency tracks that permit students to enter the profession more rapidly, or develop curricular tracks that allow students to graduate medical school after three years. Unfortunately, the accelerated residency choice is no longer an option for American Osteopathic Association (AOA) or Accreditation Council for Graduate Medical Education (ACGME) approved programs, especially for ACGME residencies, where pilot programs were attempted with great success only to be discontinued anyway. Three year medical curricular options show promise, and the adoption of a three year curricular option is a realistic possibility for both osteopathic and allopathic medical schools.

I. Graduate Medical Education Considerations

Many primary care residencies developed highly regarded "3+3" programs where the final year of medical school was combined with the first year of the student's residency. If many students, professors, schools, and hospitals favored these programs, why did the ACGME approved "3+3" programs disappear? It was not a funding issue. In the combined year, the rookie physicians paid fourth-year tuition to their medical school, and the hospital received first year Medicare resident funding for the same student. (4) It was not a quality issue. Hospitals eagerly embraced accelerated students, and multiple studies have demonstrated the high quality of the accelerated graduates. (4,5) The ACGME has not explicitly stated why the programs were discontinued, leaving one to speculate about many possible reasons. Did the ACGME feel that it was stepping on the toes of the Liaison Committee on Medical Education (LCME) by working with medical students that had not yet received their degree? Was it a political problem--did residency directors from excluded programs complain that they were unable to compete for the best residents interested in primary care?

"3+3" Programs Were Successful

Accelerated family medicine residency programs at Marshall University and the University of Tennessee attracted motivated students, often those in the top of their class. (4,5) These schools were two of twelve to receive approval in 1989. (5) In addition to the saved time, students were attracted to the prestige associated with an accelerated program. (4,5) Hospitals were pleased with the quality of the students. Authors of the Marshall study stated "[i]t has been a consistent impression of the faculty that most first-year accelerated residents have generally become indistinguishable in performance from the traditional PGY-I residents at six to nine months following orientation." (5) The program successfully encouraged its trainees to practice in West Virginia--81% of residents remained in West Virginia. (5)

The Tennessee case demonstrates the financial contentment of all parties involved. Students benefited--they received residency pay a year earlier, and were able to practice one year sooner. The medical school was content--it still received fourth year tuition dollars from the now "resident" students. Hospitals were content--they were pleased with the quality of the students, and they continued to receive Medicare GME funding for the residency positions. The Tennessee authors also noted that "[b]eneficial outcomes of accelerated residencies include a savings to society and taxpayers since there is a decrease in the time and educational financing for the production of a well-trained physician." (4)

The following observations from the University of Tennessee were promising.

"The key finding of this study is that, when compared to the traditional curriculum of 4 years of medical school and 3 years of residency (4+3), residents in the accelerated curriculum (3+3) demonstrated performance scores equal to or better than their non-accelerated counterparts. Using annual In-training Examination scores beneath the 20th percentile as one indicator, accelerated residents scored better than their peers. Further, these accelerated residents frequently distinguished themselves as chief residents and with other honors. These Tennessee students were, on average, in the middle of their classes academically, and [the] data suggest[s] that students need not be at the very top of their class academically to succeed in an accelerated program. All students achieved the objective milestones of licensure and passage of the ABFM certification examination, despite the shorter and less-costly training." (4)

Will Residency Programs Generate Independent Accelerated Options?

If residencies decide to increase their focus on established competencies rather than lockstep "meaningful contact hours," residency programs could offer residents the opportunity to complete the residency at an accelerated pace. These new accelerated tracks would need to overcome two main hurdles. First, the AOA and ACGME would need to rewrite program certification language establishing an exact number of required residency years before a student may become board certified. When a student has met these competencies and passed the licensing examination, the student could be fully certified without regard to how quickly these tasks may have been accomplished.

The second barrier is imposed by hospitals, which have numerous financial incentives to prevent rookie physicians from finishing residency earlier. Convincing hospitals to allow residents to leave "early" will be difficult because residents provide a cheap source of labor, and hospitals average almost $100,000 of Medicare funding per resident. (6) Hospitals do not want to give up this direct source of income, especially during the resident's last year, when the resident is providing very efficient and effective care. Outdated payment incentives established by the Centers for Medicare and Medicaid Services (CMS) increase hospital efforts to defend an old and inefficient training system. Actions by Congress to correct misguided financial incentives may be required before accelerated residencies are possible.

A Creative Family Medicine Program

Today, family medicine and other primary care residencies struggle to retain talented students, and it is not uncommon for allopathic family medicine residencies to be filled entirely by international medical graduates. The West Virginia Family Medicine Rural Scholars Program (WVFMRSP) attempts to entice students into family medicine with a similar prestige factor, but without the ACGME prohibited reduced year of training. The student's fourth year of medical school is treated like the first of residency, but the student still must complete three years of residency after graduating from medical school. Program participants receive a $10,000 stipend during their fourth year of medical school, avoid the match process, and will have considerable unscheduled time to conduct research during their final residency year. (7)

The WVFMRSP is a creative idea given West Virginia University's inability to enact a "3+3" program. In the meantime, other schools might increase their competitiveness for residents by adopting similar programs. The WVFMRSP treats a fourth year medical student just like a first year resident with relatively few benefits to the student. The student does receive the $10,000 stipend, but does not receive residency pay, and the student will still spend three more years as a resident. While the research year might be very valuable and important to some students, one might speculate that the final year is dedicated to research because the young physician has completed family medicine training, but the residency director is simply not permitted to "graduate" students due to the requirements of the ACGME and/or AOA. The WVFMRSP's existence provides evidence that students are capable of beginning residencies after their third year of medical school, and that preventing students from obtaining residency credit during their fourth year cheats the students out of a year of full-time practice.

Combined Medical School and Residency Years ("3+3" Programs) Are Not Permitted

Despite "3+3" program success, these programs stopped enrolling new students in 2001. Fourth year medical students are currently barred from participating in any residency program accredited by the AOA or the ACGME. (8,9) The "Accreditation Document for OPTI [Osteopathic Postdoctoral Training Institution] and the Basic Document for Postdoctoral Training Programs" published by the AOA states in section L subsection 2.1 that "the program shall enroll only graduates of COCA [Commission on Osteopathic College Accreditation] accredited COMs [Colleges of Medicine]." (8) The ACGME Institutional Requirements in section II. A. 1. similarly states that residency applicants must be "graduates" of a medical school. (9) Without a change to the "graduate" requirement in these documents, "3+3" programs will never again be permitted.

If one were to convince the ACGME or AOA to allow non-graduates (i.e. fourth-year medical students) to enter residency programs, many state laws use similar language requiring "graduate" status to achieve the temporary practice rights afforded to medical residents. The West Virginia Secretary of State Code of State Rules contains a regulation that "[a]n application for an educational training permit shall include proof that the applicant is a graduate of a medical school approved by the AOA." (10) In many states, regulations may need to be amended to provide exceptions for "3+3" program participants.

Drs. Steven Berk, Michael Ragain, and Troy Fiesinger attempted to start a "3+3" family medicine residency program at Texas Tech by submitting a proposal to the ACGME in early 2009. (11) They hoped to establish a "3+3" example that could be followed by multiple family practice residencies across the nation.11 According to Drs. Berk and Ragain, favorable responses to the proposed accelerated "3+3" program were received from the American Board of Family Medicine, the Association of Departments of Family Medicine, and the Association of Family Medicine Residency Directors. (11) In spite of this support, the proposal was declined by the ACGME. The group redirected its efforts toward designing a three year medical degree, and in March of 2010 it announced LCME approval for a three year medical school option open to a limited number of medical students committed to family practice. (12)

II. Analysis of the Three Year Medical School Curricular Option

Reducing the length of medical school to three years leads to considerable financial savings for future physicians and the reduced amount of time in school may make the medical field more attractive to potential applicants. A March 2006 University of Pennsylvania study determined that "even if total medical school tuition remained constant, a one year reduction in the duration of medical school still yields a financial benefit of $100,000 or more to future physicians." (3) Papers by Dr. Whitcomb and Dr. Irby developed at the Josiah Macy Foundation's Conference on "Revisiting the Medical School Educational Mission at a Time of Expansion" make salient arguments.

Dr. Whitcomb's article "Shortcomings in the Pursuit of Medical School Education Mission" states as follows:

"At present, no medical school requires all students to experience the same specific coursework during the four years of the education program. Indeed, until relatively recently, the entire fourth year of the program was elective in many schools, and it continues to be largely elective in most even today....Given the costs involved, it makes no sense to require students to spend a fourth year taking a variety of electives that are not deemed to be core elements of the program."13 Dr. Irby's article titled

"New Models of Medical Education" states as follows:

"There should be three primary options for the fourth year: 1) direct entry into residency if all competencies are met; 2) remediation of deficiencies if competencies are not met; and/or 3) pursuit of scholarship and electives. This structure will allow a reduction in the time to practice, reduce student debt, and still allow some students to pursue elective options and scholarship. If the student enters directly into residency or pursues the option of scholarship, the academic credit for the fourth year should be double counted for graduation from medical school and residency training in order to reduce the total amount of time before entry into practice." (14)

Some medical schools have already embraced these words of advice. As discussed above, readers should realize that Dr. Irby's recommendation that the old "3+3" programs that combined the last year of medical school with the first year of residency are no longer an option. As indicated by the recent Texas Tech experiment, interest in "3+3" programs may be fading, while interest in the three year medical school curricula may be increasing.

Accelerated Medical School Curricula Examples

We might begin by looking at the guidance provided by the medical school accrediting bodies. The undergraduate requirements specified by the COCA and LCME offer some general guidance on specific course subject areas. (15,16) COCA specifies several subject areas that should receive attention, including internal medicine, family medicine, pediatrics, geriatrics, obstetrics & gynecology, preventive medicine & public health, psychiatry, surgery, and radiology. (15) In standard ED-15 the LCME recommends that rotations in family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery be completed, and in standard ED-17 that rotations in other multidisciplinary areas, such as pathology, be made available to students. (16) The most important piece of guidance is found in standard 6.1.1 of the COCA documentation, closely mirrored in standard ED-4 of the LCME documentation (16), and it states that "[t]he minimum length of the osteopathic medical curricula must be at least four academic years or its equivalent as demonstrated to the COCA. Guideline: The curriculum should provide at least 130 weeks of instruction." (15) This 130 week requirement appears to be the only explicit timing requirement for medical schools seeking to develop an accelerated curriculum. Both the COCA and the LCME have approved three year medical school programs that are currently in place. In the discussion that follows, we will consider five medical schools (four LCME and one COCA) that offer innovative curricular options, each with its own flaws and advantages.

Duke University School of Medicine--A Research / Dual Degree Oriented Curriculum

The traditional two years of basic science courses are completed during year one, required rotations are completed in year two, year three is spent conducting research or work toward a dual degree, and year four is dedicated to elective rotations. (17) If the Duke student opts to pursue a dual degree not directly related to medicine during the student's third year, this student will only be receiving three years of medical education prior to receiving an MD. This curricular model may not be suitable to the majority of medical schools. Due to the large numbers of dual degrees and an increased research focus, Duke medical graduates may be more likely to have careers outside the standard practice of medicine--either in a research or administrative capacity--and Duke's innovative curriculum prepares its students accordingly. With regard to dual degree programs, Duke is not unique. Many medical schools across the country offer dual degree programs, and graduates often find ways to graduate from both programs in only four years.

University of Minnesota Medical School--A potential 3.5 Year Curriculum?

The Minnesota curriculum allows students to complete medical school in 3.5 years via the "Flexible MD" program. (18) According to the admissions department, most (if not all) students use the program to extend their education, and those that have been eligible to graduate early opted to take more electives instead. (Paul T. White, Associate Dean of Admissions, Minnesota Medical School, Personal Communication on June 24, 2009.) While some medical schools could look to this type of curriculum as one more possibility to attract students with diverse needs, it is not the ideal model for schools looking to offer an accelerated option.

University of Calgary Faculty of Medicine & McMaster University Faculty of Health Sciences

Calgary students complete a fairly standard series of first and second year basic science courses oriented around a "clinical presentation" curriculum. (19) The third (final) year, students can choose the amount of time they wish to allocate a clinical subject area, 4 to 12 weeks, and they have 10 weeks of pure electives. (19) McMaster students attend school 11 months out of the year and use a problem-based block learning approach to qualify for their MD degree at the end of their third academic year. (20) McMaster students complete basic science courses in 1.5 years, and spend 1.5 years in clinical rotations. (20)

A study comparing the three year Calgary curriculum to other four year LCME approved Canadian curriculums stated that "the three-year curriculum developed at the U of C produces an equivalent graduate--and one who might possibly be slightly better in communications and professionalism skills--than those who graduate from four-year medical schools in Canada." (21) A Canadian Medical Association Journal article argues that the fourth year is not necessary, and points out that there is no hard evidence that the fourth year is vital, or prepares students to be more competent physicians. (22) "Without systematic evaluations, deans of medicine will be left with only tradition as a defen[s]e when education ministers demand better evidence, given the high professional and social costs. As for medical students, they should ask whether a fourth year will make them better and wiser physicians rather than simply older and poorer ones." (22)

Lake Erie College of Osteopathic Medicine

The Lake Erie College of Osteopathic Medicine (LECOM) is currently the only osteopathic school offering a three year curriculum leading to a doctoral medical degree. LECOM's three year program, known as the Primary Care Scholars Pathway (PCSP), is open to anywhere from six to twelve students in each entering class. (23) The chief mechanism used by LECOM for saving educational time is the elimination of "audition" clinical rotation electives. (24)

April of their second year students begin to complete sixteen four-week clinical rotations. (24) For COMLEX II & PE eligibility purposes, the traditional 'third year' of medical school is considered complete after the eighth clinical rotation, and comprehensive review time for both parts one and two of the COMLEX are built into the curriculum. (24,25)

The PCSP created by LECOM is a small step in the right direction. It rewards students for entering needed primary care areas of family practice, general internal medicine, and general pediatrics. Unfortunately, the independent study element of the program is unappealing to many students and physicians, and the program is only open to a limited number of students. The PCSP relies on contractual obligations to ensure students to go into one of the aforementioned primary care areas upon acceptance into the PCSP, and they will face financial penalties amounting to a fourth year of tuition if they violate the terms of the contract.

What if other medical schools developed three year curricular options that were open to all students, allowing students to elect whether to pursue the accelerated track at the end of their second year, when they are more informed and better able to make this decision? If required third year rotations focus heavily in primary care areas, students will lack the "audition" electives needed to gain interest and experience in highly competitive specialty areas, likely leading most accelerated students to select primary care residencies without any contractual obligation. Students uninterested in primary care may still wish to pursue the accelerated pathway, choosing to replace their fourth year of medical school with a rotating internship to prepare for the residency of their choice.

Conclusion

The amount of knowledge that medical students must master has grown substantially since the 1970's. Few continue to argue that all of the basic science courses can be taught in one year, even though Duke medical students somehow manage this challenge. In the early 1970s, it was possible to practice general medicine after a single post graduate internship year. This was why it was important that future physicians receive two years of clinical education while in medical school. Today, even if medical students spend only one clinical year in medical school, they will still have a minimum of four years of clinical education prior to practice. Two years of basic sciences are needed, but two years of clinical rotations are often unnecessary, and students should be afforded the opportunity to enter residency programs after a single year of clinical training. The table on the opposite page may help to clarify this difference.

Medical schools that are preparing students to be practicing physicians, especially in primary care specialties, could create a three year curricular option by removing a year of clinical "audition" rotations while leaving the two years of basic sciences largely untouched. Schools might expect students participating in accelerated medical school curricula to achieve similar levels of success compared to students enrolled in "3+3" programs. A three year medical school option can be expected to have a larger impact than the "3+3" programs, which were limited to a small number of primary care residencies. It is important that accelerated programs be set up as "options" available to students rather than a new requirement of all students. This will allow schools to gauge student interest in the accelerated program, while accommodating students that wish to stay for a fourth year. Accelerated medical school options can be clinically structured to encourage students to enter needed primary care fields. Students opting to remain for a fourth year could be permitted to pursue a variety of clinical electives, research interests, or dual degree work. We have found a faster route to practice, now it is up to medical schools to embrace it.

Advantages and Barriers Medical Schools Might Encounter When Enacting a Three-Year Option

Advantages:

1) Increased Premedical Student Interest and Awareness of the medical school

a. Many students may prefer the opportunity to finish their degree one year earlier

b. Desired class size increases may be easier with higher application volumes

2) Ease of implementation--No need to make changes to basic science curricula

3) Less stress on already established clinical rotation sites

a. Fewer preceptors will be needed (since there are fewer fourth year students)

b. Decrease in administrative expenses associated with fourth year students

c. Desired class size increases will not be inhibited by a lack of preceptors

Barriers:

1) Total tuition revenues may decrease--Students electing to pursue the accelerated track might pay higher tuition rates for the extended curriculum during their third year, but these students would not be expected to pay the standard fourth year of tuition

2) Some clinical rotation sites might resist adjustments to their rotation schedules

3) Ensuring students obtain desired residencies by appropriately handling the temporary surge in graduating student volume as the first class of three year graduates matriculate

4) Logistical difficulty scheduling COMLEX or USMLE exams for accelerated students

References

(1.) American Association of Colleges of Osteopathic Medicine. Student Debt Rises. Chevy Chase, MD: 2007. Available at: http://www.aacom.org/about/fastfacts/Documents/FastFacts/FF-Finance-01.pdf. Accessed September 21, 2009.

(2.) Association of American Medical Colleges. Medical Student Education: Cost, Debt, and Loan Repayment Facts. Washington, DC: 2008. Available at: http://www.aamc.org/programs/first/debtfactcard.pdf. Accessed September 21, 2009.

(3.) Dorsey ER, Nincic D, Schwartz JS. An Evaluation of Four Proposals for Reducing the Financial Burden of Medical Education and Training Facing Future Physicians. Acad Med. 2006;81:245-251.

(4.) Delzell JE, McCall J, Midtling JE, Rodney WM. The University of Tennessee's accelerated family medicine residency program 1992-2002: an 11-year report. Fam Med, 2005;37(3):178-83.

(5.) Petrany SM, Crespo R. The Accelerated Residency Program : The Marshall University Family Practice 9-year Experience. Fam Med. 2002;34(9):669-72.

(6.) MedPAC Report to the Congress: Improving Incentives in the Medicare Program: Chapter 1: Medical Education in the United States: Supporting Long-Term Delivery System Reforms, June 2009, 135. Available at http://medpac.gov/chapters/Jun09_Ch01.pdf. Accessed September 21, 2009.

(7.) West Virginia University, West Virginia Family Medicine Rural Scholars Program, (http://www.hsc.wvu.edu/eastern/som/pdfs/RuralCurr/RuralScholarsfinal.pdf). Revised 2009. Accessed September 21, 2009.

(8.) American Osteopathic Association, The Accreditation Document for OPTI and the Basic Document for Postdoctoral Training Programs, 2008, Available at http://www.do-online.org/pdf/sir_postdoctrainproced.pdf. Accessed September 21, 2009.

(9.) ACGME Institutional Requirements, 2007, Available at http://www.acgme.org/acWebsite/irc/irc_IRCpr07012007.pdf. Accessed September 21, 2009.

(10.) West Virginia Board of Osteopathy, Title 24 Legislative Rule, Series 1 Licensing Procedures for Osteopathic Physicians. Available at www.wvsos.com/csrdocs/worddocs/24-01.doc. Accessed September 21, 2009.

(11.) Ortolon K. 3+3 = family physicians: tech wants accelerated residency program. Tex Med. 2008;104(12):43-45.

(12.) Jaschik S. Will Medical Schools Join 3-Year Degree Trend. Inside Higher Ed. March 2010. Available at http://www.usatoday.com/news/education/ 2010-03-25medical-school-early_N.htm.

(13.) Whitcomb ME, Shortcomings in the Pursuit of the Medical School Education Mission. Josiah Macy Foundation--Revisiting the Medical School Educational Mission at a Time of Expansion. 2008;1:136-160.

(14.) Irby DM, New Models of Medical Education. Josiah Macy Foundation--Revisiting the Medical School Educational Mission at a Time of Expansion. 2008;1:161-194.

(15.) American Osteopathic Association. Accreditation of Colleges of Osteopathic Medicine: COM Accreditation Standards and Procedures. Chicago, IL: American Osteopathic Association; 2009. Available at: http://www.do-online.org/pdf/SB03-Standards%20of%20Accreditation %20July%202009.pdf. Accessed September 21, 2009.

(16.) Liaison Committee on Medical Education. Functions and Structure of a Medical School--Standards for Accreditation of Medical Education Programs Leading to the MD Degree. Washington, DC: American Medical Association; 2008. Available at: http://www.lcme.org/functions2008jun.pdf. Accessed September 21, 2009.

(17.) Duke University School of Medicine. About the Duke Curriculum. (http://medschool.duke.edu/modules/som_curriculum/ index.php?id=2). Revised 2009. Accessed September 21, 2009.

(18.) University of Minnesota Medical School. Flexible MD. (http://www.meded.umn.edu/admissions/flex_md.php). Revised 2009. Accessed September 21, 2009, 2009.

(19.) Faculty of Medicine University of Calgary. Overview of the Curriculum. (http://www.medicine.ucalgary.ca/mdprogram/ prospective/introduction). Revised 2009. Accessed September 21, 2009.

(20.) McMaster University Faculty of Health Sciences. Michael G Degroot School of Medicine Overview. (http://fhs.mcmaster.ca/main/medschool.html). Revised 2009. Accessed September 21, 2009.

(21.) Lockyer JM, Violato C, Wright BJ, Fidler HM. An Analysis of Long-Term Outcomes of the Impact of Curriculum: A Comparison of the Three-and Four-Year Medical School Curricula. Acad Med. 2009;84:1342-1347.

(22.) Flegel KM, Hebert PC, MacDonald N. Is it time for another medical curriculum revolution? CMAJ. 2008;178:11.

(23.) Lake Erie College of Osteopathic Medicine. LECOM Learning Pathways & Curriculum. (http://www.lecom.edu/pros_pathways.php). Revised 2008. Accessed September 21, 2009.

(24.) Bell HS, Ferretti SM, Ortoski RA. A Three-Year Accelerated Medical School Curriculum Designed to Encourage and Facilitate Primary Care Careers. Acad Med. 2007;82:895-899.

(25.) Ortoski RA, Keith DS, Haen MA, et al. The LECOM Primary Scholars Pathway: An Innovative 3 Year Curricular Design--The First Class. Erie, PA: 2008. Available at http://www.aacom.org/events/annualmtg/past/2009/posters/Documents/ Ortoski_PCSP%20The%20First%20Class.pdf. Accessed September 21, 2009.

Philip Eskew, JD, MBA

2nd Year Medical Student

West Virginia School of Osteopathic

Medicine
 Clinical Years
 BS CR PG Total

1970's 3 yr program 1 2 1 3
Current 4 yr program 2 2 3 5
Proposed 3 yr program 2 1 3 4

 Minimum Total Years Needed to

 Graduate Reach Full

1970's 3 yr program 3 4
Current 4 yr program 4 7
Proposed 3 yr program 3 6

BS = Basic Science years, CR = Clinical Rotation years, PG =
Post-graduate years
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Author:Eskew, Philip
Publication:West Virginia Medical Journal
Geographic Code:1U5WV
Date:May 1, 2010
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