Changes in Medicine: Medical School

Reference as: Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7. (Click here for a PDF version)

I recently retired and have been encouraged to write about what has changed in medicine. However, the changes have been sufficiently extensive that one editorial would be too long. Therefore, this will be the first of several editorials examining medical school, residency, fellowship and practice.

The beginning of my own medical career was 1972 when I entered medical school, graduating in 1976. My reasons for choosing the specific school I entered were several: 1. A scholarship was provided that paid tuition; 2. It was a state school and otherwise relatively cheap; 3. The school would accept me after 3 years of college and without a college degree; 4. It was the medical school of my undergraduate school and I knew many of the entering students; and 5. I was told that it mattered less where you did your medical school training than where you did your residency. I saw no reason to delay admission to obtain a college degree and wanted to proceed with my medical education.

Most medical students in 1972 were like me, white and male. The most obvious change in the past 40 years has been the increasing number of women. My class of about 150 had only a few, maybe 5, women. The percentage of women graduates has gradually risen until in 2009-2010, women received 8,133 (48.3%) of the 16,838 MD’s awarded (1). However, the numbers of underrepresented minorities has not kept pace with the increasing percentage of women. The number of blacks graduating from medical school has modestly risen from about 700 in 1980 to a little over 1109 in 2008 with a rise in Hispanics from a few hundred in 1980 to 1183 in 2008. Yet those numbers still only represent 6.9% and 7.3% of medical school graduates, respectively, far below the 12% for blacks and over 15% for Hispanics of the general population (2,3).

Over 30 years of academic medicine I have not observed much change in the medical students’ abilities by the time I see them on a pulmonary or critical care rotation their senior year. The high numbers of applicants suggest that medical school acceptance is still difficult and the mean grade point average from college of an entering student is still well above 3.5. There has been little significant change in medical school education since the Flexner report in 1910 (4). Most medical schools still consist of 2 years of pre-clinical and 2 years of clinical education just like it did when I matriculated way back in 1972-6.  There have been the occasional novel educational programs in medical schools such as 3 year programs, a combined 6 year undergraduate and MD, or earlier clinical introduction, but most of these have fallen by the wayside. I’ve witnessed graduates from several of these programs and these medical education experiments do not seem to have adversely affected the medical students’ performance by the time I see them their senior year. I still find them bright, enthusiastic and articulate and ready to continue their journey to becoming doctors as house officers.

However, a major change which may be influencing medical training and career choice is the debt incurred by medical students. Although poverty was common in my class of 1976, large debt was rare. Now approximately 86 percent of U.S. medical students graduate with some debt, and of those, the average debt is almost $160,000 (6). Students at Doctor of Osteopathy (DO) schools appear to be particularly hard hit. In the US there are only 26 osteopathic schools compared to 133 allopathic medical schools that offer the MD degree. Yet, 6 of the top 10 medical schools that lead to the most medical student debt are osteopathic schools. Medical students graduating from those 6 schools averaged over $198,000 of indebtedness in 2009 (7). It has been claimed that this debt is a major influence on residency choice with fewer students going into residencies as primary care physicians because of their debt (7). However, medical student debt seems less likely to influence residency choice since most residencies pay about the same. Rather it seems that income potential after completing training may be having some influence. Primary care physicians often receive incomes half of some specialists (6).  Medical students realize this income differential and for some may be a major influence on choosing a specialty.

The concern that medical student indebtedness can influence the rest of their careers has been voiced by many and I echo this concern. This is especially true given that medical students face at least 3 years as a house officer, where salaries of about $50-60,000/year is insufficient to allow quickly paying off student loans. Although it seems unlikely that the high cost of some medical schools can be justified, I would not suggest Government cost regulation of medical school fees. My own experience with over 30 years of Government bureaucracy is that inevitably they will dictate medical curriculum based on politics, rather than science. Instead, I would propose a system of relieving medical student debt by allowing some students to obtain debt forgiveness by Government service. More on this in the later editorials in this series.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. https://www.aamc.org/download/153708/data/charts1982to2011.pdf (accessed 7-10-11).
2. http://www.scribd.com/doc/53281274/Minorities-and-Medical-Education-AAMC-Facts-and-Figures (accessed 7-10-11).
3. Cammarata J. Minorities in Medicine: Still an Unmet Need. Medscape 2010 http://www.medscape.com/viewarticle/720541 (accessed 7-10-11).
4. Flexner A. Medical Education in the United States and Canada, 1910. Available online at http://www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf (accessed 7-10-11).
5. http://www.washington.edu/uaa/advising/downloads/gpamcat.pdf (accessed 7-10-11).
6. Prep V. Weigh Medical Student Debt, Specialty Choice. US News and World Report.  2011. Available on line at http://www.usnews.com/education/blogs/medical-school-admissions-doctor/2011/06/20/weigh-medical-student-debt-speciality-choice (accessed 7-10-11).
7. Hopkins K. 10 Medical Schools That Lead to Most Debt: Some students are graduating with more than $200,000 in debt. US News and World Report. 2011. Available online at http://www.usnews.com/education/best-graduate-schools/articles/2011/04/14/10-medical-schools-that-lead-to-most-debt (accessed 7-10-11).
8. Back PB, Kocher R. Why Medical School Should Be Free. New York Times. 2011. Available online at http://www.nytimes.com/2011/05/29/opinion/29bach.html?_r=2&ref=contributorshttp://www.nytimes.com/2011/05/29/opinion/29bach.html (accessed 7-10-11).

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.