Accepted: Why Should Medical School Take Four Years? [Episode 268]

Why Should Medical School Take Four Years? [Show Summary]

Dr. Deborah Powell believes that a competency-based medical education can be just as effective if not more so than the traditional four-year model that has been in existence for over 100 years. She has been testing that theory with an innovative program called EPAC (Education Across the Continuum in Pediatrics), where four medical students per year are selected to progress through a competency-based program and move on to residency at the same medical school once they have proven they have acquired those competencies. The program currently has two groups of residents moving through, and once they finish their residency Dr. Powell aims to show that these residents are just as successful as those with the highest board scores.

Interview with Dr. Deborah Powell, Dean Emerita of the University of Minnesota Medical School [Show Notes]

Our guest today is Dr. Deborah Powell, Dean Emerita of the University of Minnesota Medical School and professor in the Department of Laboratory Medicine and Pathology at the University of Minnesota Medical School. At the University of Minnesota, Dr. Powell instituted the medical school’s Flexible M.D. program, an individualized model of medical education designed to be more adaptable to students’ career and learning goals. Dr. Powell served as chair of the AAMC Board of Directors from 2009-10 and was the first female chair of the AAMC Council of Deans in 2004. She is currently working on a pilot study of a new, competency-based model for training medical students who want to go into pediatrics that combines undergrad and medical education. This model is currently being tested in four US medical schools including the University of Minnesota.

Dr. Powell, let’s start with the basics. Why do you want to move away from the 4-year model, which has been in existence for about 100 years? What’s wrong with it? [2:03]

Intrinsically there is nothing wrong with it, but nobody has ever said four years is necessary for a medical school education. It was proposed first by Abraham Flexner after a model in use by many US medical schools at the time which had two years of basic science followed by two years of medical education. No one has ever proven that amount of time is needed to complete a medical education and move to residency training. There have been several examples of three year medical schools. There was a famous one back in the 70s when the fed government felt we didn’t have enough doctors, so the four years was crammed into three years and it didn’t work out very well. The main point is that everybody learns at different paces – some people need more time, and some people need less. I am not a big fan of time-based education, I think it should be more about flexible medical education that is competency-based.

What is a competency-based model? [4:28]

The idea is that you would have a defined set of competencies which could be knowledge, skills, attitude, or all of the above that students would be expected to achieve at a specific level of achievement, at which point they would be deemed ready for the next stage of their education. With that kind of a model you can allow some flexibility, because students will achieve competencies faster or slower than others. The problem is that we currently live in a time-based medical education system, and a competency-based system should be time-variable, moving when you are ready.

What competencies would you like to see? [6:17]

The Association of American Medical Colleges (AAMC) a few years ago developed 13 core competencies for medical students, which they said were necessary for students to move from medical school to residency, and they include things like developing a differential diagnosis for a patient who comes in with a certain set of symptoms and being able to interpret laboratory tests, and they are now testing those competencies in medical schools around the country, so they are the combination of procedural and diagnostic skills. The question is how to evaluate these skills, which is why people are skeptical of this system. Because it is not like filling in a bubble. Exams are still important but are not the only thing. For many of these competencies you need to have careful and repeated observation by skilled preceptors seeing the students over time and seeing their improvements. That group of clinician evaluators is really important for a competency-based framework, requiring faculty commitment since it is a lot more work. But it is also a lot more rewarding, and faculty involved really enjoy it. It is very active, takes a lot of time, and the big problem is that the faculty are very busy. Faculty in med schools are expected to do research, or see lots of patients, so time for teaching gets squeezed.

What’s Education Across the Continuum in Pediatrics (EPAC)? How does it work? [13:14]

This was a program I wanted to do because I wanted to know if we could test a flexible, individualized, time variable, competency-based education, and if we could do this across what everybody calls the continuum – medical school to residency to practice. Our continuum is currently segmented. We have medical school and it stops, residency and it stops, and then people go into practice. There isn’t a linkage across, so we chose pediatrics, because the American Board of Pediatrics was really anxious to do educational innovation.

We had to get permission from all of the accreditation agencies to try this out, but the idea was to design a pathway for a few medical school students to work with pediatrics program directors working with the residency programs and clerkships. We would design a competency-based pathway, and an evaluation system, and put the framework in place and agree upon when students were ready to move into residency – it could be shorter than four years, could be longer. The schools that agreed to this (UC San Francisco, University of Colorado, University of Utah, and University of Minnesota) agreed to take four classes of four students each, and offer them a residency position at that school, with the student staying at that school for medical school and residency.

Some schools were really skeptical and didn’t want students to go early, but at Minnesota we now have two cohorts of residents and have been able to see that all of them were able to go to residency at some point during their fourth year of medical school, so we’ve shown that no one needs to go longer, and in fact they all have gone sooner than the traditional model. We are carefully following these students in residency to show that these students perform just as well as students in their residency following a four-year medical school. We have to show that our assessment was accurate, and the only way to do that is to look at the whole cohort of residents they are with. Minnesota usually take 25 residents a year, so EPAC students are less than a quarter of the class. So far they are doing fine, and if that continues then we will have proven that we can do this model. All students need to pass the graduation requirements of their schools and the USMLE exam, but they are not required to get certain grades. It isn’t supposed to be about scores, but about being licensed.

What are some of the disadvantages of this type of model? [25:58]

For some they haven’t liked being singled out, and brought away from their cohort. The EPAC students are in their own clerkship, which has made some students feel a little guilty, since they know there were more students in the cohort that wanted to do it, and why was I chosen? Some of them get scared about the idea of going into residency early – am I really ready for this? But the vast majority have been pleased so far.

My sense is that there could be a lot more resistance to the competency-based model than team-based learning, or earlier clinical exposure, or shortening of the didactic portions of the curriculum. Do you agree with me, and if so, what do you ascribe it to? [28:00]

I do agree with you, although competency-based education was really proposed back in the 70s but never caught on because it felt too new and too hard. The ACGME then moved sort of to a competency-based model with milestones for residency programs so it brought it into the mainstream because everyone had to do it but there was still busywork. The resistance is two-fold – how do you create the framework and how do you evaluate it. In a world where we’re used to multiple choice exams, bubbles, and numbers, people are scared about this system.

One thing about EPAC is that we have shown that you can create this framework and you can evaluate and assess it. When our EPAC students are through with residency we can show they do just as well as the standardized framework. If you can show you can do it, it’s just as good if not better, and students like it, that takes things a long way. The corollary is that it has to be individualized and that is not efficient. We are probably going to end up with a hybrid model, with more competency frameworks but not completely because schools need to have certainty and budgets and things that everybody can rely on, so consistency rather than flexibility is important. Residency directors like everybody to start July 1, so ours took a leap of faith to start off cycle. I think competency-based education is here to stay and people are getting used to the idea. If we can show that competency-based students are just as effective as those with the highest board scores we can get people to move away from that numbers system, which would be a great service to the medical profession.

Are other schools contacting you about implementing this model? [33:27]

They are. There are a number of schools that wanted to be in EPAC but we needed to keep it small – it has been an 11-year project, truly a labor of love. Surgery has been interested, family medicine has been interested, and other schools are interested in how they can adapt parts of it. I think we are going to see more models similar to EPAC.

This is a podcast aimed at med school applicants and students. You have decades of experience in medical education. What do you wish your students really understood about medical school that they don’t tend to get? [35:34]

I teach medical school in the first two years since I am a pathologist, and I think students have an incomplete understanding of how much work medical school is. They know it is hard and they know they need to do a lot of studying, but they don’t understand the sheer volume of knowledge they need to incorporate, and for some it overwhelms them. Some get really frustrated since there is so much medical knowledge out there and everyone thinks their subject and specialty is the most important and you need to learn a lot of facts. It is a different kind of learning. There is a lot of challenge for some students who haven’t found their right learning style. I wish they had a better sense of volume and pace.

Another thing I wish they would think about is why they want to be a doctor. Medical education is very expensive and very long – why do they want to help people as a physician as opposed to as a nurse practitioner or physician assistant or clinical psychologist? Other careers are very rewarding. I think students often have an idealized view of medicine and haven’t asked themselves that question.

What advice would you have for someone considering a medical school education? [40:10]

I am actually working with my grandson right now as he considers medical school. Aside from asking him why he wants to be a doctor, I try to express how important it is to be able to work with people, and lots of different kinds of people. What is he going to do to see if he really likes working with a really diverse group of people, and how is he going to test that before he applies? You need to be able to work with people collaboratively, so I advise prospects to think about what experiences they have with really diverse groups of people, and whether or not they get joy from working in that environment.

What would you have liked me to ask you? [43:19]

If I am optimistic about medical education, which I am. I think students have a lot to teach us since they are coming to school with a lot more skills and learning styles than we have ever considered. I see more schools want to embrace a real partnership with students around their learning so I think we will see innovation in medical education.