What If We Completely Overhauled the Structure of Medical Education?

When talking about improving medical education, many experts comment on decreasing time spent in college, revamping pre-med courses, restructuring medical school to emphasize clinical learning, or even shortening medical education to 3 years. The nuances are limitless and multiple medical schools have taken on their own models to improve the practice of future physicians.

But what if we think even bigger to a completely different structure? Imagine a world where all MDs/DOs start their medical education with a physician assistant/associate (PA) degree. Then after 24 months of clinically focused and intense education, every PA is required to work for 12 months in the primary care setting (family medicine, internal medicine, pediatrics, or obstetrics and gynecology). During this time, the PA would take the Physician Assistant National Certifying Exam (PANCE), and then apply to a subsequent 2-year medical school where she or he would earn an MD/DO degree.

In this abbreviated 2-year medical school, the PA would first undergo 6 months of deeper didactic learning in pathophysiology. Then the PA would experience traditional medical student core rotations such as: internal medicine, surgery, ob/gyn, psychiatry, neurology, family medicine, pediatrics, and emergency medicine for 12 months. During all of these rotations, the PA would be expected to function at the level of an intern. Finally, the PA would spend 6 months in electives to broaden their medical experience. At the end of this 2-year medical school, the PA would earn their MD/DO degree and would be able to practice full scope primary care medicine without supervision as long as they pass the United States Medical Licensing Examination (USMLE).

If physicians decide to further specialize, then they would apply to residency. However, they would not have to complete an internship year, and could apply to any specialty directly and spend the next 3-7 years learning about that field through residency. As with the traditional medical education approach now, fellowship opportunities would exist after residency is completed and the physician becomes board eligible/certified.

I love being a physician, I wouldn’t trade it for any other job in or outside of healthcare. I’m grateful for the process that I’ve been through and all the teachers and patients I’ve had along the way who helped me learn and grow. Our training is arduous and necessary because clinical medicine is not black and white and it takes time, effort, and perseverance to learn the nuances that save patient lives in the most challenging situations. Furthermore, clinical judgment, leadership, and confidence that evoke change are characteristics that develop through experience and on the job training.

So why propose such a drastic change in medical education? The primary reasons are two-fold: the worsening shortage of primary care physicians and the issue of the “all or nothing” enigma.

Shortage of primary care physicians: We’re always hearing about it, but what is truly being done about it? According to “The Complexities of Physician Supply and Demand: Projections From 2018 to 2033,” from the Association of American Medical Colleges (AAMC), the U.S. will likely be short of 21,400 to 55,200 primary care physicians by 2033. This new proposed model of medical education would address the shortage on two fronts. Since all potential MD/DO candidates would complete a year in primary care as a PA, some may decide to stay and practice as a PA as a result of their exposure to the field. Furthermore, if they decide to continue to finish their MD/DO degree, they will be able to practice full scope primary care medicine immediately after finishing medical school because the students would have been practicing at a resident level throughout their clinical rotations. This would save the 3 years of residency it currently takes to practice in primary care.

All or nothing enigma: According to the American Medical Association, 92.8% of U.S. MD seniors and 89.1% of U.S. DO seniors matched in 2021. The average medical school debt is $215,900, before adding other educational debt. Imagine going through at least 8 years of school and then being informed that you cannot practice clinical medicine, even though you have met the requirements and passed the required board exams to graduate medical school. That was the story of over 2,000 unmatched doctors in 2021, left with the burden of debt but no clinical career to show for their efforts. This new proposed model of medical education solves this problem. Potential applicants can practice as PAs from the very beginning and turn it into a career if they wish. If they desire further education, they can pursue the MD/DO and immediately practice as a general practitioner afterwards. The applicant would only have to pursue residency if they want to further specialize. Equally as important, this alternate system allows for off ramps for applicants at multiple points in time, which is important because people’s life situations or interests may change. During the medical training process, students may start families or may have life altering responsibilities such as personal illnesses or deaths in the family. These events may not be conducive with the current “all or nothing” required training process to become a physician; thus, this new system can also help alleviate burnout and create more flexible paths in medicine.

The U.S. has been a leader in medical innovation for generations, but our medical education process has evolved less rapidly. Paradigm shifts on this scale may seem like science fiction, but with vision and our American ingenuity, we can overcome these modern challenges and achieve the impossible.

Rafid Rahman, MD, is an incoming physical medicine and rehabilitation resident at the University of Missouri School of Medicine. He is a member of MedPage Today‘s The Lab.