New pathways for medical student education address concerns of both students and educators

Innovative approaches to medical student education are largely driven by two key factors: a projected shortfall of up to 120,000 physicians by 2030 and escalating medical student debt, which can average $150,000–$210,000 per graduate.^1,2 Revisiting the traditional medical education model—two years of preclinical, classroom-based learning followed by two years of rotations in a clinical setting—could reduce student debt and expedite graduation for a select group of students who would like to enter the workforce sooner.

With minimal deviation, U.S. physicians have been trained in the same four-year format for more than 100 years, a structure that evolved based on the medical education reforms recommended by the Flexner Report published in 1910.^3,4 U.S. physicians average 14 years of higher education—four years of college, four years of medical school, and three to eight years of postgraduate training.⁵ This training period is much longer than in other developed countries, where students typically study for 10 years.⁵ Could alternative approaches to medical student education in the U.S. not only save time and money, but ultimately result in enhanced patient care provided by physicians who learned in a blended clinical and classroom environment?

This article describes novel and emerging approaches to medical student education, describes the challenges associated with major curriculum reforms, and outlines the College’s role in advancing the medical student training experience.

One innovation that has been introduced at eight U.S. institutions and one Canadian university allows medical students to graduate in three rather than four years (see sidebar). According to Travis P. Webb, MD, MHPE, FACS, professor of surgery and associate dean of curriculum, Medical College of Wisconsin, Milwaukee, his institution offers two tracks: a traditional four-year track that trains approximately 205 medical students annually and an accelerated three-year track that trains 20–25 students per year at two regional campuses.

“It took a couple of years of planning to determine the logistics of how we would provide the same curriculum, in other words, the same objectives and the same assessment models, for all of our students—whether they’re on the Milwaukee campus or on the regional campuses in Green Bay and Wausau—and to figure out how we could compress the time such that students would get the same breadth of training and knowledge in a shorter amount of time,” Dr. Webb said. “The way we ultimately decided to do this was to be very time intensive and to start the students in clinical exposure and clinical training much earlier and to do away with many of the breaks [vacation time] that our students in Milwaukee have.”

According to Dr. Webb, the students in the accelerated track begin their first year in July instead of August. During this year, they begin to learn basic clinical skills, such as performing the physical exam and communication and professionalism competencies before moving into the more basic science portion of the curriculum. In between the first and second year, students begin clinical rotations.

“At the Green Bay campus, students participate in a more traditional clerkship model, where they do clerkships in family medicine, psychiatry, and surgery, all in between that first and second year. At the Central Wisconsin campus, however, the program implemented a longitudinal integrated clerkship model, which allows students to experience the full breadth of clinical specialties. They begin that in June after the first year, and then they continue that training on both campuses in June of the second year. This model allows them to complete all of the required clerkship topics and diseases, exposures, and such during the third year,” Dr. Webb said. The program at the Wausau campus is now in its third year, and the program at Green Bay is entering its fourth year.

Some medical educators have expressed concerns about three-year curricula, including the possibility of higher burnout rates among students. Dr. Webb said it is important to recruit appropriate students for three-year programs. “You want to get the right students, the right fit, for the institution and for the training model. It certainly helps to have mature students who have a good idea of what they want to do with their life. I think many of the students who do well in accelerated programs have had a previous career, if you will, in nursing or some other type of health care field and already have an idea of what it means to be a health care provider. They have figured out the drivers that allow them to persevere through the challenges of rigorous medical school training,” he said.

Another factor that may curb potential burnout at the Medical College of Wisconsin is the small cohort of students who are in the accelerated track. With 20–25 students per class, the faculty and dean are able to develop a closer relationship with each student and are able to recognize and ideally mitigate any fatigue-related issues that arise. Students who seem to be struggling also have the option to decelerate into a standard four-year training model.

Another common concern regarding an accelerated medical school program is the potential for reduced physician competency. Notably, a study of the Michael G. DeGroote School of Medicine at McMaster University, Hamilton, ON—which has provided three-year curricula for more than four decades—found that “McMaster graduates were comparable to four-year graduates of U.S. and Canadian medical schools in terms of performance on standardized national examinations, preparation for and performance during residency, ability to obtain preferred first-year residencies, and percentage pursuing primary care.”⁴

Similarly, Dr. Webb said three-year program medical school graduates score as well as four-year students on the U.S. Medical Licensing Examination, and their performance during residency is just as good as or better than four-year students.

Three-year medical school programs are not a novel concept and, in fact, were determined to be suitable alternative education models during World War II and in the 1970s, driven by physician workforce shortages and a surge in the cost of medical education, much as the case is today.⁶ Furthermore, today’s medical students have the added advantage of new teaching technologies that make this model more viable than in the past.

“We have been able to replace some traditional lectures with podcasts, videos, and webcasts that allow students to digest them, quite frequently, at an accelerated speed, or they can slow it down or go back to areas that they need to review for clarity,” Dr. Webb said.

“The reliance on just book knowledge has decreased at point of care because you have access to information via your mobile phone,” he added. “The ability to look up something quickly has not yet altered the foundation of what we are teaching, but certainly it’s going to alter it in the future as we start dealing with more potential for artificial intelligence in medicine. We need to react to that and to ensure that our students are prepared to enter the workforce and be competent for years to come.”

Dr. Webb also noted that simulation is making accelerated learning more possible. “The use of simulation, whether it’s with live patients or using high-fidelity simulators, has enhanced our ability to prepare students for actual clinical encounters with real patients. We have been able to use those types of situations earlier on, when it’s much lower stakes, to allow students to have these encounters, provide them with feedback, and then allow them to take that knowledge and those skills directly to the clinic, where we have seen that they have a higher level of clinical ability than [students in] the traditional curricula.”

A 2016 survey of approximately 280 medical school deans showed that 38 percent of the educators were interested in an accelerated curriculum.⁷ “This is not a small number of education leaders who have a strong interest in this pathway for multiple reasons,” Dr. Webb said. “I am hopeful and I am confident that many institutions are considering this, and I think we will continue to see an evolution of what the fourth year of medical school looks like.”

Integrated curriculum with early clinical experience

Educators at Georgetown University School of Medicine, Washington, DC, have designed a new educational pathway for medical students, which is tethered to a curriculum that blends clinical experience with basic science over four years.⁸

According to Shimae C. Fitzgibbons, MD, MEd, FACS, MedStar Georgetown University Hospital, the Georgetown model provides more student-driven choices; that is, it is less prescriptive than a traditional curriculum and gives students the opportunity to figure out how to best use their time, with much more flexibility in when they take time off for interviews or for research.

Georgetown also offers students interesting electives or opportunities to engage in selective clinical rotations that they might not have been exposed to in the third year. “The traditional fourth year at Georgetown has shifted to starting even earlier. It is akin to making the fourth year even longer, which is in direct opposition to how some other medical schools have dealt with the issue, namely to truncate the medical school curriculum and make it more or less a three-year experience,” Dr. Fitzgibbons said.

Georgetown’s new curriculum includes approximately 18 months of foundational science, then early entry into clinical rotations, followed by more intense study of basic science, but with students selecting areas of basic science that complement their specialty interests.⁹ “This shift moves everything up and allows for a longer tail at the end. They spend the fourth year doing what they have selected to do rather than meeting core requirements,” Dr. Fitzgibbons said.

A notable challenge of implementing this student-centered, interactive-learning model was achieving faculty buy-in. “I think one thing that has existed at Georgetown, which might have made the challenge particularly difficult for us, is the segregation between the faculty who teach the preclinical years and the faculty who teach the clinical clerkships in the hospital,” Dr. Fitzgibbons said. “And that is likely similar to a lot of other medical schools—this lack of integration between those two faculty groups. Even though they are attending meetings together and designing a curriculum together, at the end of the day, the preclinical faculty go back to their offices and teach their courses, and the clinical faculty go back to the hospital and teach their courses.” Dr. Fitzgibbons noted that the courses that were easiest to update and modify for the new curriculum were the ones where course directors were paired with one academic and one clinically active physician.

The revised curriculum at Georgetown, which rolled out in 2017, also is supported by new education-based technology.^8,9 At Georgetown and many other institutions of higher learning, printed handouts have largely been replaced by digital formats, including lecture-capture tools that allow instructors to record what happens in their classroom for students to access later, as well as tools to convert PowerPoint slides and other instructional aids into digital formats that are time-saving and adaptable to the student’s individual learning style. These new technologies sometimes allow students to watch a lecture before the class meets, fostering more interaction between the students and instructor, while the use of laptops and smartphones allows students to connect with in-classroom screens in real time to ask questions and engage with peers and the professor.⁸

“I think it can be difficult for faculty to learn new teaching styles,” added Dr. Fitzgibbons. “We have a fantastic dean of assessment who’s really tried to push faculty development around very specific best practices on how to get students more engaged, how to get them to do independent learning that’s actually effective, how to keep checking back in to get more informative feedback—even in the preclinical course work. This approach makes your faculty feel more supported when they’re going through a difficult time, and it improves the end product.”

Early clinical exposure

A three-part, four-year program at The Ohio State University Medical Center (OSUMC), Columbus, integrates classroom-based basic science instruction with clinical patient care. At OSUMC, students get early clinical experience, providing patient care in the program’s first 10 weeks, including learning to take vital signs, give injections, draw blood, and perform electrocardiograms. Now in its seventh year, this program emphasizes clinical problem-solving in a team-based environment.

According to David E. Lindsey, MD, FACS, department of surgery, division of trauma, critical care, and burn, OSUMC, the Lead, Serve, Inspire (LSI) curriculum is intended to fortify key physician leadership skills, including critical thinking and knowledge synthesis. The LSI curriculum, launched in 2012, took five years to design and features a three-part approach within the traditional four-year structure. Part one emphasizes foundational science; part two focuses on thematic integrated clinical application of medicine (similar to third-year clerkships); and part three concentrates on advanced clinical management, including exposure to emergency medicine and advanced ambulatory care, in an effort to prepare students for residency in their specialty.^10,11

“The instructor enjoys the fact that students who are coming to them for a month on service, or wherever they’re attending, have chosen it rather than having been required to do so,” said Dr. Lindsey, who has been involved in the curriculum rewrite since the beginning. “The interest level of the students also is much higher. It’s much better if you’ve chosen to take something rather than if you are compelled to take it to complete your program.”

In February 2018, the OSUMC’s executive curriculum committee adopted the Association of American Medical Colleges (AAMC)-endorsed Physician Competency Reference Set (PCRS) as the core outcomes of the LSI curriculum.¹² Although these competencies outline appropriate skills for practicing physicians, medical students at OSUMC are trained to exhibit them based on their level of training. The eight core PCRS competencies include patient care, knowledge for practice, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice, interprofessional collaboration, and personal and professional development.

No matter the learning style of the individual student, progress reports are essential for keeping the learner on a pathway to success. The LSI curriculum features a student self-assessment component with individualized education goals developed with feedback from faculty coaches. Evaluation is competency-based, according to Dr. Lindsey, and uses multiple milestones to measure progress, and, ultimately, help propel the student toward a categorical residency.

“What we’ve seen is a progression of our students to very few preliminary and many more categorical positions,” said Dr. Lindsey. Most U.S. medical students seek a categorical position, which offers funding for full residency training. A preliminary position typically offers only a year or two of training before entering a specialty program. “The feedback from directors across the country where our interns have landed, as to their preparedness from day one, has been positive. In another six months, we’ll have data from the American Board of Surgery In-Training Exam to determine how well we prepared them to begin their surgical training.”

“We’re still looking at the data, but our hypothesis is that once a person gets a categorical residency position, there will be a decrease in the people that change specialties,” Dr. Lindsey added. One of the difficulties in residency is that 10 to 20 percent of the first-year interns will decide to choose another specialty. “Now, we want people to be in what they like, but these changes can disrupt a program because you then have to go through the preliminary pools and look for a replacement.” After experiencing that senior year of clinical experience in the field, it is anticipated that graduates will have a strong sense of the residency program they want to pursue.

The College’s role

“There are some challenges related to revamping the fourth year of medical school,” said Susan Steinemann, MD, FACS, Chair, ACS Committee on Medical Student Education. “If we really want to make that fourth year more specialty-based, we need to make sure that we have ways to provide skills training within the first three years and ways to assess competency,” Dr. Steinemann said.

“I think, historically, a lot of the skills necessary for a competent physician of any specialty have been pigeon-holed in a surgery clerkship, and often that is not enough time to teach and assess everything,” Dr. Steinmann said. “As a result, the fourth year can end up as a safety net to make sure that the students are competent to move onto residency. The College has made some real advances in this area, specifically the ACS/Association for Surgical Education (ASE) Medical Student Simulation-Based Surgical Skills Curriculum, which is aimed at the first three years and is offered to students of all specialties.”

This joint program uses simulation to help medical students have a uniform learning experience, acquire essential surgical skills that all physicians need, and build a solid foundation for further training.¹³ The simulation-based modules can be used to teach clinical skills, ranging from taking a history and conducting a physical, to signing out a patient, to inserting a central venous line with ultrasound guidance.¹³

A study published in the February issue of The American Journal of Surgery focused on whether the joint ACS/ASE curriculum could be used to teach and assess the AAMC’s core entrustable professional activities (EPAs)—13 competencies that graduating medical students are generally expected to perform independently.¹⁴ More specifically, core EPAs are activities that all entering residents are expected to perform on the first day of residency without direct supervision or the physical presence of a supervising physician. The study suggests that the “ACS/ASE curriculum is a viable model for implementing EPAs, particularly the ability to provide an oral presentation of a clinical encounter; give or receive a patient handover to transition care responsibility; and perform procedures (such as bag mask ventilation, venipuncture, inserting intravenous line).”¹⁴

“This curriculum provides the students with the opportunity to learn these skills earlier in their medical career and be assessed for competency earlier, so that by the time they hit their fourth year, they’re actually vetted and able to perform many of the skills required for a physician of any specialty,” Dr. Steinemann said. “Both the students and the faculty will have confidence that they can perform a lot of these skills independently with the requisite oversight. Then that fourth year can really be focused more on patient care.”

EPAC

The Education in Pediatrics Across the Continuum (EPAC) Project is another medical education model rooted in competency-based progression and EPAs and is currently being piloted in the U.S. The goal of this project is to determine whether the typical academic pathway—from the first year of medical school to the completion of residency—can be guided and assessed as a comprehensive program using a competency-based framework.¹⁵

According to the AAMC—which is sponsoring the EPAC Project—the “prevailing structure of both undergraduate medical education and graduate medical education continues to be both time- and tradition-based and thus at odds with a primary tenet of competency-based education, which is the attainment of competence by the individual learner within their own time frame.”¹⁵

“The EPAC pilot is one example of a unique educational innovation that could actually decelerate or accelerate medical education, depending on how the students perform,” said Lisa Howley, PhD, senior director of strategic initiatives and partnerships in medical education, AAMC. According to Dr. Howley, the pilot is designed to test the feasibility of medical education that is based on the demonstration of defined outcomes rather than on time—from early medical school through completion of residency.

EPAC was introduced in 2009 and enrolled its first students in 2013 at four institutions: the University of Minnesota School of Medicine, Minneapolis; the University of Colorado School of Medicine, Denver; the University of Utah School of Medicine, Salt Lake City; and the University of California San Francisco School of Medicine.^15,16

“As an educational psychologist, I can tell you that there is no one-size-fits-all approach,” said Dr. Howley. “I think shifting toward a competency-based model is, over time, the ideal approach. In other words, it’s not a matter of time. It may not be four years, it may not be three years—it’s how long it takes for the individual learner to develop the confidence and competence to enter into residency.”

Conclusion

Sarah J. Armenia, MS, department of surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Rutgers University, Newark, NJ, surveyed 33 fourth-year medical students who had completed their surgery rotation to assess how medical students perceive their fourth year. Most of the respondents (79 percent) agreed that completing a surgery curriculum in the final months of medical school would be beneficial before residency.

“You can’t look at your medical student class as a homogenous population anymore,” Ms. Armenia, a member of the ACS Committee on Medical Student Education, said. “Tease out during your interviews what they’re interested in because a population of students is going to be interested in getting into this field as soon as they can, and others are going to be very cautious and know they want to do some specialties.”

Central to most medical school curricula modifications is the goal of training procedurally competent physicians with a more focused, student-centered approach. These modifications are thought to generally enhance both student and instructor satisfaction and engagement. Medical education experts agree that ongoing, evidence-based research is necessary to measure the success of these programs in terms of the quality of student and graduate performance.¹⁷

References

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