Two Canadian institutions -- McMaster University and the University of Calgary -- offer three-year M.D. options. In the United States, the Lake Erie College of Osteopathic Medicine offers a three-year option for a D.O. degree. But the unusual Texas Tech M.D. program could represent a significant move in efforts to encourage more medical students to go into primary care and to find ways to minimize the costs of medical education. And it may raise questions about the fourth year of most medical degrees.
"I think Texas Tech has challenged some assumptions and I think it's good to challenge them. Others are going to be watching," said John Prescott, chief academic officer for the Association of American Medical Colleges.
In June, the Carnegie Foundation for the Advancement of Teaching will release a major study of medical education, and it will recommend, among other things, that all medical schools consider three-year options. David Irby, vice dean for education of the University of California at San Francisco School of Medicine and co-director of the Carnegie study, said that "this ought to be an option for every student -- regardless of specialty."
The Carnegie panel will recommend a focus on learning outcomes and milestones, in ways that could end the norm of four years for medical education. While some medical students might go into residencies after three years, others might focus on research projects or specialties, but not in the strict format of medical education today.
Irby said that the coming debate on medical education is likely to be controversial, and stressed that the Carnegie study will not call for any "shortening of expectations." He explained: "We have had a time-based academic program, and it works well to get almost everybody through, but it's pretty inefficient, so if you really focused on very clear, competency development, and did it more efficiently, there's no reason you couldn't do an M.D. in three years."
Steven Berk, vice president for medical affairs and medical school dean at Texas Tech, said that the program was designed out of the conviction that most of the fourth year of medical school was focused on electives in various medical specialties -- programs that are important for those considering specialized residencies, but that may not be necessary for those committed to primary care. Texas Tech believes that, with a few adjustments, it can provide those who plan careers in family medicine with the necessary parts of the fourth year earlier -- and free up the year.
Here's how it would work for students who want to enter family medicine in three years:
- First year: Curriculum would be the same.
- Summer after first year: Students would no longer get time off and instead would take a single course in family medicine that is normally part of the second year curriculum.
- Second year: Students take the normal curriculum, but add in (throughout the year) a clinical experience in family medicine (normally part of the third year).
- Third year: Students take regular rotations in fields such as internal medicine, pediatrics and psychiatry. In the eight-week rotation that would otherwise be used for family medicine, the students would take rotations in the parts of the fourth year deemed necessary: intensive care, neurology and geriatrics.
Over all, students will spend slightly less time in the curriculum than do students over four years. Berk said that when he talks with medical educators elsewhere, "everyone has been thinking about the fourth year." He said that the fourth year can be enormously important for some students in planning their careers or having unique experiences in medicine. He spent some of his fourth year while at Boston University's medical school on a Native American reservation. But Berk said that "it depends on the student" and that he believes that some "probably don't need the fourth year."
He also said that the emphasis in the fourth year on specialized electives "absolutely" draws students away from primary care. Nationally, many medical experts say that the United States needs more primary care physicians, rather than more specialists.
Then there is the financial incentive. Tuition and fees are about $13,000 a year for Texas residents, more for non-residents. Three-year students will be spared a year of tuition and living expenses, and will start earning a salary a year earlier. To encourage students to consider the option, Texas Tech will also offer a year's scholarship to participants, so together with their saved fourth year, they will end up paying half of the cost of a typical M.D.
Currently, Texas Tech's entering medical class of 140 generally has 10-12 students who are interested in family medicine. Berk said he hopes that the various incentives will eventually double that contingent. "We're not going to solve the problem nationally at Texas Tech, but if other medical schools look at this and try the same thing, this could make a difference," he said.
Berk noted that Texas Tech has long been interested in the idea of condensing the time it takes a medical student to reach the stage of practicing medicine. During the 1990s, Texas Tech participated in a pilot program -- since abandoned -- that combined the last year of medical school with the first year of a residency.
Berk said that some were skeptical of that program because those in their residency's first year were not yet M.D.'s. He said that Texas Tech tried to revive that idea -- and was rejected by the association that runs medical residencies -- before focusing on a three-year M.D. That idea won the approval of the Liaison Committee on Medical Education, the accreditor for M.D. programs.
Debates over the length of professional programs are not unique to medical education. Northwestern University and the University of Dayton have created two-year options for law students in what is normally a three-year program. And the law school at Washington and Lee University in 2008 announced that it was replacing its third-year courses with clinical programs. When these reforms were announced, some legal educators debated what was said about the value of the third year in most programs.
Prescott of the medical college association said he strongly backed the idea of experiments to determine the steps that could encourage more medical students to go into primary care, and that could minimize the tuition bills facing medical students. So he said that the Texas Tech program was "something we should take a close look at."
But he cautioned that "I don't think people can take away from this the idea that the fourth year of medical school can be removed."
Many medical students, even some who will become primary care physicians, aren't ready to commit to that path early on, Prescott said. And even for those who know their plans, many students find that the fourth year "is an essential component" of making students "into well-rounded physicians." He added that the fourth year "is an incredibly important time for many medical students."
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