AAMC Reporter: January 2009

Accelerated M.D. Programs Provide Benefits, But Still Face Skepticism

Sarah Borders is not pursuing a typical medical education. Then again, she is not a typical medical student. She was able to earn her B.S. degree in three years, and so is now wrapping up her first semester of medical school several months ahead of schedule.

"I've known since I was a child that I wanted to be a doctor," Borders said. "I studied upper-level biology early. If you don't have that motivation, it's easy to fail. I always knew I wanted to challenge myself."

A first-year student at the University of Kentucky College of Medicine, Borders is part of the school's B.S./M.D. Accelerated Course of Study program, which looks to move highly motivated students from their first college lecture to the white coat ceremony in seven years. This is one of several models aimed at reducing the time it takes to complete medical school—an idea that was popular decades ago but is gaining fresh traction as an answer to rising student debt and a shrinking physician workforce.

"It's quicker and it's cheaper," said Alan J. Neville, M.D., chair of the three-year undergraduate medical education program at McMaster University's Michael G. DeGroote School of Medicine in Hamilton, Ontario, Canada. "The modern [accelerated medical school] program is advantageous because students are only in university for three years, so they are paying less tuition and they finish faster."

In Canada, DeGroote and the University of Calgary Faculty of Medicine offer three-year medical school programs to all students. No U.S. medical school has a strictly three-year program, although approximately 20 schools offer tracks that combine undergraduate and medical education into six or seven years, according to AAMC data.

Neville said learning at DeGroote takes place 11 months out of the year, for 130 weeks—20 fewer than traditional programs—and is more problem-based than other curricula. The shortened learning time obviously makes for a highly concentrated experience, which tends to attract only the most motivated students and leaves little margin for error.

"It takes time to process information, and more time to assimilate it," said Bruce Wright, M.D., Calgary's associate dean for undergraduate medical education. "It is possible to get overwhelmed. It is a go-go-go environment. It requires us to be vigilant. We will have four or five students each year who have to step out because they are burned out."

Students who complete an accelerated program presumably do so at least in part because of the potential for big financial savings. According to a 2004 AAMC study on medical student tuition and young physician indebtedness, the "cost of attending medical school" and "the time it takes to become a doctor" were the top two reasons that seemingly qualified students did not pursue a medical degree.

A study published in the February 2006 issue of Academic Medicine found that reducing the duration of medical school from four years to three years resulted in $160,000 in total savings for general internists and $230,000 for internal medicine subspecialists. The study authors concluded that "the most effective financial means for decreasing the large financial burden of medical education is not to reduce the price of medical education, but rather to reduce the duration of training."

"Saving a year was a huge factor," said first-year medical student Borders. "I wanted to push myself and save an extra year of tuition. You put so many years into your education that saving a year is fantastic."

Another potential but more controversial benefit of accelerated programs is their role in easing a predicted physician shortage, especially in the primary care specialties, by getting more doctors into practice more quickly.

"You are able to produce more physicians one year sooner," said Wright. "If all things are equal, it allows physicians to begin their work one year earlier, which is especially important at a time when there is a shortage."

Steven L. Berk, M.D., vice president for medical affairs of Texas Tech University Health Sciences Center and dean of the university's school of medicine, said he favors a program where the fourth year of medical school is merged with the first year of residency so that students are acting—and are paid—as residents.

"Giving students this opportunity provides an impetus for them to get into primary care. They're getting paid a year earlier, and that helps the debt go down," Berk said. "We haven't been successful in getting more students interested in primary care. We're really not coming up with better solutions. It's time to start thinking outside the box."

Berk recently sent a proposal to the Accreditation Council for Graduate Medical Education (ACGME), on behalf of Texas Tech and about 20 other schools, that would establish a pilot test of his accelerated education model. An ACGME spokesperson confirmed receipt of the proposal, but was unsure when the council would review it.

Others are not convinced that accelerated medical education alone will solve the workforce problem.

"The rationale that it will provide more physicians is fallacious, unless you also increase the class size," said Thomas Schwenk, M.D., of the University of Michigan Medical School Department of Family Medicine. "They come out faster, and they come out earlier, but there are not more of them."

According to DeGroote's Neville, there is a misperception that accelerated medical school programs are focused mainly on producing primary care doctors. However, Neville noted that about 40 percent of DeGroote graduates go into a family medicine field, while 60 percent go into other specialties.

"It's not true that three-year grads can't end up getting prestigious academic or research careers," he said.

Berk rejected the idea that shorter education times mean an inferior final product.

"There is a prestige factor at work here," he said. "People are concerned this will lead to 'barefoot doctors.' But you can find students who are ready for this. Many students [in accelerated programs] actually do better on exams and attending evaluations."

C. Darrell Jennings, M.D., the University of Kentucky College of Medicine's senior associate dean for education and coordinator of the school's combined B.S./M.D. program, said accelerated education can actually help students interested in a research- or academically oriented career path.

"It helps people if they want a combined degree like the M.D./M.P.H. or M.D./M.B.A.," Jennings said. "Those are usually five-year programs, so if someone wants to use our program and then take a combined degree program, they would begin residency with their cohort. So it really opens up a lot of pathways. This kind of flexibility is hard to achieve sometimes in other programs."

At Calgary, Wright said administrators constantly monitor exam scores, LCME standards, and feedback on graduates from residency directors to determine whether they are providing high-quality education. According to Wright, Calgary completed its most recent LCME evaluation in March and encountered no significant problems.

"We have to comply with the same LCME standards as all the other schools," Wright said. "So we took great pride in this. It validated to us that we were doing the right things."

Wright acknowledged that the school, which includes a 10-12-week elective cycle in the third year, offers "significantly fewer" elective options than others, and that "that might be a downside."

"A large part of the discrepancy is elective time," he said. "We realize we're under the microscope, so we focus on making sure all our mandatory courses are the same as those at other places."

The Calgary curriculum's first two years are systemsbased, and include instruction on medical skills, global health, and population health that cut across all courses.

As for combined B.S./M.D. programs, Schwenk said that wider study is needed to determine whether their educational value is truly on par with that of traditional models.

"Of course those programs are successful, because these students are the cream of the crop," he said. "If you take top students and put them in any kind of special program, they will always do well, because they are top students and they are receiving special attention."

There is also some anecdotal evidence that today's medical students may actually prefer a longer-thannormal medical education.

"In family medicine, we're seeing students who want more training, not less," said Schwenk. "They want more expertise and experiences. They want to be a generalist physician with training in special areas."

Melanie Lo, a fourth-year University of Minnesota Medical School student, is studying infectious diseases in Tanzania as part of the school's Flexible M.D. program, which offers longer medical education experiences without extra cost.

"For me, combining career development experiences with my medical training was essential, and that seemed to be better accomplished with an extended rather than an accelerated course," Lo said.

However, accelerated program proponents noted that many students are attracted to the challenges and rewards of getting their white coats quicker.

"The three-year program attracts a certain kind of student," said Jennings. "It acts as a carrot. These students are looking for exceptional opportunities."

—By Scott Harris