Still 10-13 years is the standard minimum, and that comes with numerous downsides. Long training times are economically disadvantageous both for students and the education system, resulting in less time as a fully-trained (and fully paid) physician and more time in a less-productive trainee role. This training time is worthwhile if it results in increased long-term productivity or effectiveness as a physician - education, after all, is an investment that presumably comes with returns on that investment. However, it's not hard to imagine that all those years come with some investments that don't pan out with any regularity and could be eliminated.
Long training times are hazardous for policy makers as well. Physician supply is a tricky balance to achieve under the best of circumstances - medicine is complex and uncertain, so determining what services are necessary or how many physicians are needed to provide those services is not an exact science. Nevermind the challenge of figuring out what type of physicians are necessary and where they should be located. With training times in their current state, any adjustments to physician supply don't even start to come into effect for about 7 years.
Say we need to train fewer physicians: the main way to do that is to accept fewer medical students. But, from the start of the application cycle until the first family physicians from that cohort are fully trained, it takes about 7 years. Same if we need to train more of one type of specialist and less of another - from the time medical students go through residency applications to the end of residency (plus the now near-mandatory fellowship), it's 6-8 years. If evaluating present needs in medicine is challenging, predicting the future is damned-near impossible. Ontario took a shot at it - the Ontario Population Needs-Based Physician Simulation Model - and while it has some good insights, on the whole it does a rather inconsistent job of predicting need (most egregiously, we don't have a giant shortfall of Diagnostic Radiologists - if anything, the job market is tight).
To summarize my ramble, there are good reasons to cut down training times if feasible. How could we go about this?
1) Reduce the post-high school, pre-medical school training times
There's no real absolute need for students to do as much post-secondary education before medical school. It's not a completely useless endeavour - plenty of knowledge gained in undergrad has utility in medical school or beyond, it's the best time to develop valuable skills for the future (even if those are simple things like studying or being organized), and it's also an important time of maturation. We expect a lot of physicians and learning how to be an adult on top of that is no small task.
Yet, a full four years of undergrad - or in some cases, more than that - probably isn't necessary for all applicants either. Accepting more students after third year, or exceptional students after second year, could shave a year or two off the total training time for physicians. However, given the competitiveness of medicine, older applicants will almost always have an advantage, given their additional time to mature and develop knowledge or skills, so the average impact on training time would likely be fairly minor.
Another option is to accept students right out of high school. Many countries, especially in Europe, do this already. Their medical schools are often longer with this route - 6 years is the standard, rather than Canada's 4. It's a plausible option: after all, physicians in these countries are well-trained and of high quality. However, there are also differences in the way medicine is practiced and how the educational system is structured, especially at the secondary level, that may make direct-from-high school programs problematic or less effective in Canada.
The current trial at such a strategy - Queen's QuARMS program - is not likely to give us many answers. By taking only 10 students, there's a very high likelihood that their students are not going to be representative of the high school population as a whole. If QuARMS proves problematic, that might mean something, because if even the best high school students struggle, the rest won't likely have much success. Yet, if these students succeed - and there's little reason to think they won't - it won't tell us much about whether it makes sense to switch to such a model.
There's an additional downside here. While overall training times for physicians would shorten somewhat, this approach actually lengthens the time it would take for policy changes to have an effect. Numbers of new physicians would be locked in about 9 years in advance, rather than 7.
2) Reduce the time in medical school
Most medical schools are 4 years long. Is this necessary? Absolutely not. How do I know? Two schools in Canada do just fine with 3 years.
Pre-clerkship does not need to be as long as it is at many schools. Too much of the information transmitted is of marginal value to the actual practice of medicine, important for a small subset of practitioners, or better learned in clerkship anyway. In addition, while summers are great for relaxation and extra-curriculars, they're also great for forgetting everything you learned in the school year. Cutting pre-clerkship in half would save a lot of money, shorten training times and doesn't seem to hurt educational outcomes.
There would be some downsides, however. Less time for ECs, research, and observerships means less opportunity to explore different specialties or to develop a broader career. Still, no one seems to care much about ECs, research can be done longitudinally during school, and most people don't settle on a specialty until clerkship anyway. The drawbacks to losing a year of pre-clerkship may not be overly meaningful in the long run.
In addition, cutting a year out of medical school would take a big reorganization, with plenty of bumps along the way, and schools are typically quite hesitant to cut anything they think is worthwhile. Expensive but proven is a safer option for schools to take. Still, it's an option we know that some schools have had reasonable success with.
3) Shorten training times after medical school
Perhaps the most controversial suggestion is to reduce the post-graduate training times for physicians. Residency is where the bulk of physician training happens. Both residents and practicing physicians are loathe to reduce residency times for fear of producing unprepared physicians.
Still, there may be potential to reduce overall training times. Some specialties seem to do alright with shorter training times in the US (though there aren't always comparable - for example, IM fills a much different role in the US than in Canada).
Improvements in education during residency also show some potential to speed the process along. Competency-based evaluations with a focus on simulation-based education has been put forward as a method to get residents competent faster.
It's also not as though physicians finish residency with nothing left to learn. The first year of independent practice is often as educational as the residency years and learning in medicine is an ongoing effort throughout a physician's career. Residents don't have to be perfect physicians when they finish up their formal training, they just need the experience and ability to practice safely.
A growing topic in post-graduate training for physicians is the growing necessity of fellowships. In the past, fellowships were optional - additional training physicians could take to develop specialized knowledge, allowing them to tailor their practice to their interests. However, fellowships - in some cases more than one - have become increasingly required to obtain any job at all, not just those that call for the super-specialized skills a fellowship typically develops. This can, and should, be addressed.
Unfortunately, the main mechanisms for addressing this education inflation are a better tailored supply of physicians, creating a bit of a chicken-and-the-egg scenario. Physician training times are too long because there are too many physicians in some specialties, but because training times are so long, reducing the number of physicians in those specialties is exceedingly difficult.
In summary, there's good reason to think about reducing training times for physicians, but no real easy answers. I think the first step should be to reduce medical schools from 4 years to 3 years by cutting out a year of pre-clerkship, reducing summers to no more than a month, and adjusting that time to focus on the bare essentials. Other options are worth exploring, if only tentatively, for their feasibility to reduce costs of investing in new physicians without reducing the payoff from that investment.
Long training times are hazardous for policy makers as well. Physician supply is a tricky balance to achieve under the best of circumstances - medicine is complex and uncertain, so determining what services are necessary or how many physicians are needed to provide those services is not an exact science. Nevermind the challenge of figuring out what type of physicians are necessary and where they should be located. With training times in their current state, any adjustments to physician supply don't even start to come into effect for about 7 years.
Say we need to train fewer physicians: the main way to do that is to accept fewer medical students. But, from the start of the application cycle until the first family physicians from that cohort are fully trained, it takes about 7 years. Same if we need to train more of one type of specialist and less of another - from the time medical students go through residency applications to the end of residency (plus the now near-mandatory fellowship), it's 6-8 years. If evaluating present needs in medicine is challenging, predicting the future is damned-near impossible. Ontario took a shot at it - the Ontario Population Needs-Based Physician Simulation Model - and while it has some good insights, on the whole it does a rather inconsistent job of predicting need (most egregiously, we don't have a giant shortfall of Diagnostic Radiologists - if anything, the job market is tight).
To summarize my ramble, there are good reasons to cut down training times if feasible. How could we go about this?
1) Reduce the post-high school, pre-medical school training times
There's no real absolute need for students to do as much post-secondary education before medical school. It's not a completely useless endeavour - plenty of knowledge gained in undergrad has utility in medical school or beyond, it's the best time to develop valuable skills for the future (even if those are simple things like studying or being organized), and it's also an important time of maturation. We expect a lot of physicians and learning how to be an adult on top of that is no small task.
Yet, a full four years of undergrad - or in some cases, more than that - probably isn't necessary for all applicants either. Accepting more students after third year, or exceptional students after second year, could shave a year or two off the total training time for physicians. However, given the competitiveness of medicine, older applicants will almost always have an advantage, given their additional time to mature and develop knowledge or skills, so the average impact on training time would likely be fairly minor.
Another option is to accept students right out of high school. Many countries, especially in Europe, do this already. Their medical schools are often longer with this route - 6 years is the standard, rather than Canada's 4. It's a plausible option: after all, physicians in these countries are well-trained and of high quality. However, there are also differences in the way medicine is practiced and how the educational system is structured, especially at the secondary level, that may make direct-from-high school programs problematic or less effective in Canada.
The current trial at such a strategy - Queen's QuARMS program - is not likely to give us many answers. By taking only 10 students, there's a very high likelihood that their students are not going to be representative of the high school population as a whole. If QuARMS proves problematic, that might mean something, because if even the best high school students struggle, the rest won't likely have much success. Yet, if these students succeed - and there's little reason to think they won't - it won't tell us much about whether it makes sense to switch to such a model.
There's an additional downside here. While overall training times for physicians would shorten somewhat, this approach actually lengthens the time it would take for policy changes to have an effect. Numbers of new physicians would be locked in about 9 years in advance, rather than 7.
2) Reduce the time in medical school
Most medical schools are 4 years long. Is this necessary? Absolutely not. How do I know? Two schools in Canada do just fine with 3 years.
Pre-clerkship does not need to be as long as it is at many schools. Too much of the information transmitted is of marginal value to the actual practice of medicine, important for a small subset of practitioners, or better learned in clerkship anyway. In addition, while summers are great for relaxation and extra-curriculars, they're also great for forgetting everything you learned in the school year. Cutting pre-clerkship in half would save a lot of money, shorten training times and doesn't seem to hurt educational outcomes.
There would be some downsides, however. Less time for ECs, research, and observerships means less opportunity to explore different specialties or to develop a broader career. Still, no one seems to care much about ECs, research can be done longitudinally during school, and most people don't settle on a specialty until clerkship anyway. The drawbacks to losing a year of pre-clerkship may not be overly meaningful in the long run.
In addition, cutting a year out of medical school would take a big reorganization, with plenty of bumps along the way, and schools are typically quite hesitant to cut anything they think is worthwhile. Expensive but proven is a safer option for schools to take. Still, it's an option we know that some schools have had reasonable success with.
3) Shorten training times after medical school
Perhaps the most controversial suggestion is to reduce the post-graduate training times for physicians. Residency is where the bulk of physician training happens. Both residents and practicing physicians are loathe to reduce residency times for fear of producing unprepared physicians.
Still, there may be potential to reduce overall training times. Some specialties seem to do alright with shorter training times in the US (though there aren't always comparable - for example, IM fills a much different role in the US than in Canada).
Improvements in education during residency also show some potential to speed the process along. Competency-based evaluations with a focus on simulation-based education has been put forward as a method to get residents competent faster.
It's also not as though physicians finish residency with nothing left to learn. The first year of independent practice is often as educational as the residency years and learning in medicine is an ongoing effort throughout a physician's career. Residents don't have to be perfect physicians when they finish up their formal training, they just need the experience and ability to practice safely.
A growing topic in post-graduate training for physicians is the growing necessity of fellowships. In the past, fellowships were optional - additional training physicians could take to develop specialized knowledge, allowing them to tailor their practice to their interests. However, fellowships - in some cases more than one - have become increasingly required to obtain any job at all, not just those that call for the super-specialized skills a fellowship typically develops. This can, and should, be addressed.
Unfortunately, the main mechanisms for addressing this education inflation are a better tailored supply of physicians, creating a bit of a chicken-and-the-egg scenario. Physician training times are too long because there are too many physicians in some specialties, but because training times are so long, reducing the number of physicians in those specialties is exceedingly difficult.
In summary, there's good reason to think about reducing training times for physicians, but no real easy answers. I think the first step should be to reduce medical schools from 4 years to 3 years by cutting out a year of pre-clerkship, reducing summers to no more than a month, and adjusting that time to focus on the bare essentials. Other options are worth exploring, if only tentatively, for their feasibility to reduce costs of investing in new physicians without reducing the payoff from that investment.
As long as the supply of aspiring doctors greatly exceeds demand any sort of requirements can be imposed upon them and they will comply.
ReplyDeleteTrue, but I like to think medicine does understand the difference between "can" and "should", even if it collectively takes us a while to figure out what we should be doing.
DeleteInsightful read! Just curious as a Canadian working in the clinical field in the US, what is the role difference between Canadian and US IMs that you mentioned?
ReplyDeleteThe difference largely relates to primary care. In the US, IM is the main adult primary care specialty. In Canada, IM does virtually no true primary care, as Family Physicians cover that role almost exclusively. As a result, there are many more internists in the US compared to Canada.
DeleteLikewise, when talking about duration of training, IM is at least a year shorter residency in the US than in Canada. However, if you view IM as primary care providers, they actually get a year more of training than most primary care providers (Family Physicians) do in Canada. As I said, in this case, fair comparison of training times becomes difficult!
Thanks for explaining, I was always a bit fuzzy about primary care in the US (between terms like GP, family physician, internist)
DeleteP.S. Sending you good vibes for your CaRMS match!
Good CaRMS vibes are always appreciated!
Delete