Medical school, the old boy's club

[WeBuyAndSellJunk]

I don't mean to imply that medical school is for men only with that title, but more so that it is the only accepted pathway to becoming a doctor. With such a shortage of providers, especially in primary care roles, I struggle to understand why the system can't value experience, individual skill sets, and current competency as sufficient in some regard. Obviously, further education is warranted, but there is such a huge pool of capable people that don't really require the traditional 4+residency route. I think this system is going to collapse relatively soon, but docs I've talked with disagree. It hasn't been sustainable for several years. Why is it persisting in this country? What gives?

[EMEDPA]

good question. the system used elsewhere in the world (UK, etc) with BS+MD in 5 years makes a lot more sense to me than our 8 yr pathway.

[WeBuyAndSellJunk]

Patient mortality and morbidity are apparently fairly equivalent between the systems also, granted they do function somewhat differently (yes, each has its flaws). And at that, the UK system takes people from the equivalent of highschool to MD, not even people that already have established skills that could translate to medical practice.

[EMEDPA]

yup, a fair pa to md would probably be 18-24 months.

[WeBuyAndSellJunk]

I'm sure there are several variables, but I can't help but think that part of the issue is that medical school is a huge cash cow and that few doctors are okay with people attaining their job with "less input".

[Gordon, PA-C]

I'm sure there are several variables, but I can't help but think that part of the issue is that medical school is a huge cash cow and that few doctors are okay with people attaining their job with "less input".

 

True, but that's the case for all professions, not just MDs.  Everybody is acting as a cartel in their own self interest.  It's why PAs in MIssouri vociferously opposed letting non-residency trained MDs working as "physician assistants"

[WeBuyAndSellJunk]

Granted, but there is a reason I put less input in quotes, i.e. I think that many physicians believe that there is only 1 true path to becoming a capable doctor. It is simply a form of oligarchy that isn't going to help supply the massive need for doctors. With that in mind, I agree that a traditional route is the correct path for a traditional student, but there seems to be some inherent idea that unless you are practicing under a MD/DO license that your knowledge is of a lesser quality. You are right though, it is the same in many professions, but I would certainly defend the same idealogy that a competent worker shouldn't be held back by the lack of formalized knowledge in a subject... it is simply not the only means of learning. It is a waste to society to force that worker to learn the same skills for the sake of formality. Obviously take that with a grain of salt as some regulation is needed, especially considering safety concerns.

[cop to pa]

Remember, the Flexner report came out 105 years ago.  It took that report, coupled with huge media coverage and Congress perking up to change the medical education format from what was little more than OJT and observation to what we have now. 

 

I'm afraid it will take something similar: with data, Congressional pressure and huge media coverage to convince the medical education structure that the pendulum has swung too far to the other extreme, and that non-traditional paths (well regulated) can produce just as competent physicians.

 

Anyone want to be that pariah?

[Guest Paula]

^^^^^The NPs  already have done it with data, congressional pressure, huge media coverage.....etc.......

[cop to pa]

Not quite what I meant. NPs don't have an abridged medical school to make them MDs. It will take another effort like the one 100 years ago for that to happen.

[WeBuyAndSellJunk]

It seems like part of the problem is that there is no organization that clearly benefits from a new setup. Where is the financial incentive to do all of this research, lobbying, etc...? It almost seems like it will have to be performed by the government with the idea that the system cannot persist in its current form. And importantly, while there may be overlap, this is different than the idea of PAs becoming completely autonomous.

[BruceBanner]

Personally I think the US pathway is getting too long and complicated. There has to be a better way to train doctors, at least GPs. I just talked to a new colorectal surgeon who is about 37-38 and JUST now opening his own practice. It's crazy. 

 

I support a BS-->MD pathway with an accelerated primary care focus. Something like 8 years from college to practice.

 

Similarly I still support a sane and fair PA to MD pathway. Mandate 5 or so years of IM/FP experience, then have an accelerated didactic phase with a direct entry into residency, no clinical rotations. 

 

The big, obvious problem is it is too hard to standardize....BUT if it could be done and made feasible for established PAs I think a lot of people would do it. The existing bridge program now isn't really a bridge at all.

[cop to pa]

I like this. Maybe allow a PA with 5+ yrs of practice to self study and take step I (to prove a sufficient knowledge base to the AMA).  Then have a bridge program of about a year to a year and a half to cover needed didactic for the doctoral aspect while being matched for residency, then off you go. 

 

This would in no way be a "shortcut" to some kid trying to find a way around medical school, but would allow medical professionals to advance themselves even further, much as the allied health practitioner to PA route did when the career started.

[WeBuyAndSellJunk]

As a serious question, is there currently any group/organization that could help perpetuate this idea? At least the idea of a better bridge...

[cop to pa]

You may be better off pushing a marble up a mountain with your nose. As you said: "old boys club"

[Kwame E]

They should at least make medicine like pharmacy, where you don't have to have a Bachelor's to start a program. Just finish the pre reqs + MCAT + shadowing/volunteering/whatever. I think that's how it is in Canada and Europe.

 

I know there are BS/MD programs out there, but those are few and far between, super competitive and limit you to primary care most of the time.

 

Medical School could probably be cut down to 3 years too.

 

Longer schooling doesn't necessarily mean a better outcome.

[kargiver]

Anything cloaked in deep tradition and rich in values will not change easily.  Once you are in you are in - but It is not in their interest to do so.  And they hold the cards - make no mistake.

 

The way the system is structured now, MDs are at every level of reimbursement decisions, have powerful lobbies, have friends of friends who are politicians, etc.  Its how the game works.  Its how it always has.

 

Cost is not an effective reason for them to change the model.  If politicians have no incentive to shut off the printing presses at 18 trillion in debt, what makes anyone think that there is any incentive to cut back what they pay to MDs as opposed to PAs and NPs?  It isn't about money.  The ONLY issue that matters is access.

 

You want to define your own desitiny?  Then define your own destiny.  But pandering to another profession to garner recognition to do what they do, without going through the rituals and training they have gone through, will never work out.  The NPs know this - they now have their own approach and in the end, will win this war with the MDs. Why?  They made it about access, not money.  And they don't want the MD rituals - there is no need for it.

 

PAs as a rule have always felt "thankful" to the MDs for the opportunity to practice medicine, yet it has never occurred to them collectively, in a moment of epiphany, that they can do what the docs do too - without their blessing.  Some of us do it every day.  But those of us who know this are the exception to the rule, not the rule itself.  When the profession decides it wants to be independent, and is willing to do what it takes to bring the fight to those who need it, then there will be no need for bridge programs, recognition by MDs, or anyone else.  But the fact remains - PAs still think themselves "Assistants" and the new people coming into the field have bought the BS message hook, line and sinker.  They will not be the impetus for change.

 

G

[kittryn]

I don't mean to imply that medical school is for men only with that title, but more so that it is the only accepted pathway to becoming a doctor. With such a shortage of providers, especially in primary care roles, I struggle to understand why the system can't value experience, individual skill sets, and current competency as sufficient in some regard. Obviously, further education is warranted, but there is such a huge pool of capable people that don't really require the traditional 4+residency route. I think this system is going to collapse relatively soon, but docs I've talked with disagree. It hasn't been sustainable for several years. Why is it persisting in this country? What gives?

 

I just did a 6 mo stint in primary care - after 8 years in surgery - and I ran screaming. 20m/patient, back to back, all day; you never know what's coming in the door so you have to grapple with a whole new set of potentially scary problems with every 20m visit, no time to document, the implicit expectation that you "do your documenting at home"; insurance co's dictating what you can prescribe and to who, endless prior authorizations for same; bean counters micromanaging your documenting to keep up with RVUs..... NEVER have I experienced such stress, even when working 7-12s in a surg service (7 days on/7 days off). I will never do PC again. I'm now working in a practice that doesn't even take insurance, so I can take 45m with each patient. much better, fee-for-service.