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Subject: RE: interesting new 3 year medical school model

Ok, I finally feel compelled to overcome my aversion to “respond to all” email bloat and chime in here. 

I am surprised by the widespread support for an educational model that has failed miserably to produce
the workforce America needs, particularly for our most underserved communities.  Defending the
current curriculum seems to me akin to those supporting the current health care system “because it
works for me”.   Systematic change is going to be needed if we have any chance of making a dent in the
miserable state of our health care “non-system”.  We have finally leaped off that cliff in hopes of finding
something better, and physician education had better do the same or risk becoming irrelevant.

Like Eric, I fondly remember some of my 4th year rotations, however I was paying $11,000 tuition, and
going to school at time when medical students were actually allowed to write notes in the chart, and
were expected to touch patients and were allowed to do things to them.  Today,  students—even 4th
year sub interns-- have been marginalized to the point that they  can only document a tiny fraction of
the patient note (if any) and it is entirely possible to graduate from OHSU having never delivered a baby
or even started an IV, AND they are paying nearly $40K for the “privilege” of being nearly irrelevant to
the care of the patients they see.  Even without the substantive changes to make it the education better,
simply  relabeling the 4th year of medical school as  “internship”, (especially in a model that closely
integrates medical school with residency)  allows students to participate in patient care in ways that are
currently impossible, and are unlikely to change in the forseeable future.  For a subset of motivated
students, the advantages of reducing  their medical school debt by half and the time by 25%, could far
outweigh continuation of  the current 4th year that is often filled mostly with fluff. 

 The Texas Tech model is not being applied to the entire class, only to 10 well selected students with
characteristics to suggest that they will be able to handle the compressed curriculum (they have the
same requirements as the regular students, just compressed into a shorter time and rearranged to make
more sense).  If you want to add a year to the curriculum, there is good reason to believe that residency
is the place to do it, not the current 4 th year medical school model.   The admissions process needs to
change as well.  Currently,  medical students nationally are predominantly selected for their ability to
grind through Organic Chemistry and take tests well, not necessarily for their likelihood of being a good
doctor who will go where they are needed and do what needs done when they get there.  While there
are many reasons for this, a predominant one that we need to get a grip on is that we systematically
select the students that are easiest to teach, not necessarily the students that will be the best
physicians.  If fact, most of our current students don’t need to be taught at all.  They are selected to be
good academically and almost all of them continue to perform well while in medical school regardless of
the quality of teaching.  If, however,  we are ever going to be serious about addressing the racial and
social inequities in medical education,  we will need to recognize that there are some great potential
physicians out there who haven’t fully figured out how to jump through all the hoops, and some of them
will actually need to be interacting with faculty  teachers on a regular basis to be successful.  There are
faculty at this medical school (our department is an exception, I know) who rarely, if ever, interact with
medical students and many who do “interact” don’t actually teach or mentor.   Students with MCAT
scores of 27 can be very successful, but more of them will need our help than those with MCATS of 36.
But there is an inverse correlation between MCAT score and likelihood of providing care  to the
underserved.

The issue has come up that a compressed curriculum is somehow “dumbs it down”,  as has the
perception that primary care/family medicine will be perceived as less important  if the time were
shortened.  The proof is in the pudding.  A well structured curriculum that actually integrates a 3 year
medical school curriculum with a 3 or 4 year residency is at least as likely to produce a quality product
that we want and need as the system we have now.  Give me 5-10 well selected students per year  with
assured interest in primary care, with less debt and sooner (and more) exposure to the populations that
we want them to serve and we can make a significant dent in the primary care shortage.  Howard
Rabinowitz’s data says that if every medical school in the country produced 5-10 students for rural
practice per year, the entire rural workforce shortage could be erased in just over a decade.  If half the
schools produced 10-20 we could achieve the same thing.   The scope of this is not unattainable,  but the
attitude  and structural changes needed to achieve it may be.

We,  as medical educators, had better get our thinking caps on and begin to challenge the status quo or
healthcare reform will fail  simply for lack of an appropriate workforce, and we will be blamed.  It is not
the fault or the responsibility of the government, it is OUR responsibility.  Wistfully longing for the old
days, or labeling our students slackers, or tweaking the current curriculum won’t cut it.  Not only that,
but I have had meetings with 4 presidents of foundations, and Oregon DHS since health care reform was
enacted, and each and every one of them has point blank asked me what the AHEC and OHSU plan to do
that is creative and innovative to address the physician workforce issues that we face with health
reform.  Each and every one of them has also said  point blank that they will not be funding anything
that smacks of same old, same old.  There is a hunger for real change and reform among the funders,
including the federal and state governments  as well as private foundations.  No one out there believes
that what we are doing now is adequate, and neither should we.   If you don’t like the Texas Tech model,
then lets create our own, but doing nothing for the sake of nostalgia about the way it used to be, or
because we can’t get our act together, or fear what change may bring is unacceptable.

Oregon AHEC will be putting on a Summit on Medical Education this summer--details to follow.  You are
all invited to participate and make a difference.

Lisa

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