Why Medical Schools are Four Years Long?…

Why Medical Schools are Four Years Long?

Ever since I can remember, medicine and access to healthcare has played a central theme in many of the things I have been involved with. Yet, how was it that medical education in America grew to provide such an elite education and train many of the world’s top health professionals?

If we look at the history of medicine it has certainly come a long way, and how physicians are trained has changed even more.  Historical figures such as Hippocrates, Pedanius Dioscorides, ibn Zakariya al-Razi, Ibn al-Nafis, and Ibn Sīnā are not only known for their influence on medicine, but also for being botanists, philosophers, geologists, poets – the list goes on.

Indeed medicine has changed. Over 200 years ago physicians employed bloodletting to treat our first president, George Washington, a giant man at 6’3, to treat of signs of a cold which later proved to be fatal. It wasn’t the cold that had killed him though. Washington had been drained of half his blood in less than a day. Today, however, as physicians continue their interdisciplinary practices, their education has become standardized.

The Shift in Education

In the 19th century most medical education was through three systems:

1. an apprenticeship system, in which students received hands-on instruction from a local practitioner;

2. a proprietary school system, in which groups of students attended a course of lectures from physicians who owned the medical college; or

3. a university system, in which students received some combination of didactic and clinical training at university-affiliated lecture halls and hospitals.

It wasn’t until the turn of the century that Abraham Flexner was commissioned by the American Medical Association and the Carnegie Foundation for the Advancement of Teaching that medical schools began to shift their philosophy of education. With the acceleration of medical technology, growth of evidence-based medicine, and the growing importance of physicians/scientists in society, the shift in improving medical education was on the brink of making the medical school system we see today.

After 18 months and 155 medical schools, Flexner concluded that admissions to a medical school require a minimum of a high school diploma and two years of university education focusing on basic science. John Hopkins University School of Medicine became the gold standard and the Flexner Report stressed the importance of medical education being four years: two years of training in laboratory sciences followed by two years of clinical rotations in a teaching hospital.

Flexner examined five principle areas at each school. Now what I find interesting is that these are the same characteristics students look for in the medical schools they are applying to. These are:

1.    entrance requirements;

2.    size and training of the faculty;

3.    size of endowment and tuition;

4.    quality of laboratories; and

5.    availability of a teaching hospital whose physicians and surgeons would serve as clinical teachers

Medical Education Today

Today, however, medical education is changing at an even faster pace. Meet now Dr. David Irby, the Vice Dean for Education at UCSF. He is co-author of the anticipated book: Educating Physicians: A Call for Reform of Medical School and Residency set to be released June 1, 2010. The book is rumored to highlight many new models for a medical education, including a three-year fast track program- already being seen in universities such as Tulane and proposed at UC Merced. These programs tie generally an undergraduate education with a graduate education equaling a total of six years of education versus the traditional eight (4 college + 4 medical). But at Lake Erie College of Osteopathic Medicine a three-year medical education is set to encourage for those who choose to go into primary care. This creates an interesting incentive for individuals who are looking to fill the large gap of primary care physicians in the US.

Physicians need to possess medical skills as much as they do business acumen and an understanding of how insurance companies and the government will potentially challenge to future of medicine. There is an intense effort today by major tech companies such as Google Health and Microsoft Health Vault to encourage a shift in the way physicians understand technology and communication with their patients (a topic for later discussion). As patients begin playing an active role in their own health, so will the role of a physician and their training requirements.

With the increasing financial pressures, medical education will shift. To what? I can only imagine. In 1988 Ebert and Ginzberg proposed that the last two years of medical school that is spent in the clinic should not have a tuition fee, and that students should receive a stipend similar to the practice of graduate medical education. In 2010, Irby et al could potentially revolutionize the medical education system we see today.

p.s. Happy New Year!

| if I knew all the words I would write myself out of here. |


Beck A. The Flexner Report and the Standardization of Medical Education. JAMA.  2004;291:2139-2140.

Cooke M, Irby DM, Sullivan W, Ludmerer KM. American Medical Education 100 Years  after the Flexner Report. NEJM. 2006; 355:1339-1344.

Ebert RH and Ginzberg E. The Reform of Medical Education. Health Affairs. 1988.  Supplement 5-38.

3 thoughts on “Why Medical Schools are Four Years Long?…

  1. Nice historical research my friend. I should like to see tuition being waived for the final 2 years as the students will be actually contributing somewhat to patient care. I wonder if this would also help attract even more applicants seeing as the cost of education would decrease by half. Though, I’m happy this isn’t happening this year. You and I have enough competition because of this economy. Good luck and happy hunting my friend!

  2. Very interesting post Ali! I just had a convo w/ a Harvard doc on just this topic. Also, I have been doing a lot of reading on technology and business in medicine and completely rescind my previous statement about medicine not being fundamentally concerned with this stuff.

    I think I said this out of a feeling that medicine is “nobler” than money or technology, without thinking about the incredibly positive, streamlining influences attention to these factors can have. In fact, attention of this sort is vital. The key is to balance efficiency/technology with the fundamental humanism of the field…

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