The members of the U.S. medical school class of 2025 entered high school this fall. Shocking to think of, isn’t it? More shocking is to wonder what and how to teach when they enter medical school in just eight years? And how will they complete their training—will there be enough residency positions for them? These questions can and should keep medical educators awake at night.
The students entering high school this year are undoubtedly the most connected in history—to each other, to their families, and to virtually every source of extant knowledge, information, and data.
After four years of high school, most of these students are going to be even smarter, more able to understand the concepts and limitations of big data and analytics, and more immersed in the applications of handheld and smaller technologies to daily life and work. Thanks to the Beloit College “Mindset List for the Class of 2017,” we know that today’s entering college students have known multi-tasking almost from birth, carry the world’s reference libraries with them on tablets, and with their smartphones and social media are never out of touch with anyone.
Possibly they will wear their smartphones/tablets as wrist devices and reporters/recorders of their health status. They will have taken some college courses as MOOCs, and used social media in politics, shopping, relationships, housing, and finding a career. Perhaps for those interested in medicine, they will have begun to understand how technology can make them more caring and humane, while giving them greater preventive, diagnostic, treatment, and rehabilitative capability than has ever been possible.
Over the next eight years, the health care industry will see major advances in electronic health records, mobile medical technology, telemedicine, biomedical sensors (including smartphones), increasingly knowledgeable consumers with their own smartphone apps for measuring and monitoring their health status, and the organization and financing of health care delivery. All of these will increase primary care and specialist physicians’ abilities to provide effective patient education and care.
“Point of care” technologies offer primary care docs the opportunity to change the dynamics among specialties and with hospitals, while shifting more patient–physician interaction to ambulatory settings, including the patient’s home. The psychic and economic benefits to PCPs are obvious, as are the cost savings. But, among the medical faculty that will be in place eight years from now, who will be able to teach about and with these technologies and overlay that information on the anatomic, physiologic, and biochemical fundamentals underlying human health, illness, and injury?
Medical schools must develop and deliver a coherent curriculum that probably will change from year to year. Faculty development will be about medical science and technology as much or more than teaching techniques and teaching technology. Real teachers—those who care and reach students’ minds—will have to be identified, cultivated, rewarded, recognized, helped to become even better, and identified as role models for those who are still learning to teach.
All the years of medical school will have to become more effective. Rather than eliminate the fourth year, we must maximize its purpose and educational value while developing professionalism and standards of ethical behavior. Serious electives, independent study, curriculum improvement projects, practice and business literacy, health services, biomedical research, and formal coursework in public health and business administration can make the fourth year more valuable and productive beyond interviewing for residencies.
If the 2025 graduates choose a very good residency program in a direct patient contact specialty, they will spend their first few weeks finding out what they don’t know about patients and engaging with them, discovering the weak points in their own knowledge and skill bases, and putting a corrective plan into action. By 2025, they will find that many of their patients are already fully aware of their health status and vital signs as well as of the usual treatment of their condition. Many of them will be members of one or more disease-oriented foundations or support groups. Instead of bringing a shopping bag full of reprints and medical texts to their appointment, they will open the smartphone on their wrists, which will also hold their medical history, a link to their EHR, and a longitudinal record of their vital signs.
Genomics will provide information and guidance perhaps never before available to a physician. But the mental calculus of putting together a diagnostic and treatment plan, comparing it to other relevant mental models, and reaching an evidence-based decision, even aided by technology, still will be the province of the physician working within his or her personal knowledge, skills, experience, and professional judgment. Doing that mental calculus while teaching and counseling a patient has to be taught and learned. It is not an inborn skill.
Will there be enough residency positions for the 2025 graduates to complete the education and training essential for them to be high-quality professionals?
In a word, no. There won’t be enough residency positions unless there is major federal legislative action accompanied by substantial funding in the near term.
Late last month, both the AAMC and the AOA reported record numbers of applicants and enrollments for the 2013 entering class in allopathic and osteopathic medical schools. Enrollments and the number of schools have increased over the past five years in response to calls from policy analysts and physician workforce specialists for thousands more physicians, especially in the primary care specialties. But, no physician can be licensed for medical practice in the United States without additional training, usually at least a three-year residency.
The number of residency positions has not increased by any appreciable amount since 1997. Expansion of GME funding through CMS is the only way, right or wrong, that enough additional residency positions to meet the need can be supported. There are legislative proposals in Congress, but only voter demand can jar a dysfunctional House of Representatives into action.
Mapping projected physician workforce shortages against the districts of Congressmen who oppose increased residency spots could generate a call to action for activists and advocates. Medical schools, new and old, must develop some strategies and priorities for action. Most important, the patient-as-voter must become an impatient voter.
—James E. Lewis, Ph.D., is an independent consultant to departments and schools of medicine, teaching hospitals, cardiovascular and cancer research and clinical programs, medical professional associations, disease oriented foundations, consulting firms, pharmaceutical companies, components of the National Institutes of Health, the Centers for Communicable Diseases, and the predecessors of the Center for Medicare and Medicaid Services. Previously he served as Deputy Dean for Operations and Vice President for Academic Administration, The Mount Sinai School of Medicine and Medical Center, New York City, where his academic title was Professor of Medicine and Health Policy; and Senior Executive Officer, Department of Medicine, University of Alabama at Birmingham, where his academic titles were Professor of Medicine and Adjunct Professor of Sociology. He can be reached at firstname.lastname@example.org.