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Disrupting Medical Education

A combination of MOOCs and community-based training sites could result not only in better education for future physicians, but in higher quality, more widely available, and affordable health care for everyone.
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Harvard Medical School. (Photo: Tim Sackton/Flickr)

Harvard Medical School. (Photo: Tim Sackton/Flickr)

Arizona State University’s recent announcement that it is joining with edX, a non-profit open online learning platform founded by founded by M.I.T and Harvard, to offer a full freshman year online for as little as $6,000—payable upon successful completion—has re-kindled significant debate about the structure and cost of a college education.

While affordable and open access to an undergraduate education is important to the health of our democracy, why stop there? What if the best and brightest of tomorrow’s physicians were to leave medical school with almost no debt? What effects would this have on the health of our nation? And with the cost of a private medical education climbing an average of three percent per year, to a median of $70,000 annually, is this even possible?

Next month, 18,000 newly minted physicians will enter the United States health care workplace. Over three-quarters of them will graduate with a median of $170,000 in education debt. With average medical-school graduates facing an additional three to seven years of low-wage training, most will enter their mid-30s with the equivalent of a large mortgage—before starting a family, before purchasing a home, before saving for college and retirement.

Given that the first 18 months of medical school is essentially the same for 18,000 students at 150 medical schools, why must 150 different professors teach the same basic science content at the exact same time?

Does this impact their choice of how and where to practice? Of course it does. While many students enter medical school with dreams of general practice and serving the underserved, studies repeatedly show that the size of medical-student debt significantly impacts their practice choice, forcing them to choose higher paying and well-reimbursed specialties.

Despite the promise of the Affordable Care Act, physician compensation practices remain tethered to the provision of treatment, not the maintenance of health, thus rewarding higher volumes of patients seen and procedures performed. It is not a big leap to wonder about the subtle daily impact that this crushing debt plays on our nation’s rising health care deficit, measured at $1,100 billion in 2014 and expected to rise to a staggering $1,700 billion by 2020.

Despite their debt, physicians today remain well compensated. The median salary for a family physician in private practice today is $189,000. For a dermatologist it is $311,000; for a neurosurgeon, $517,000. While these salaries have remained fairly stable over the past 10 years, the cost of higher and medical education has risen precipitously.

Ten years ago, the students I advised worried about their debt, but knew they would be able to manage it regardless of what specialty they chose. Now, many of my advisees assume that they will die with this debt—and they are likely right. More and more, they are choosing careers in the higher-paying specialties, leaving behind their noble dreams of primary care and care of the underserved.

Increasingly, this critical need is being filled by teams of advanced practice nurses, physicians assistants, and physician graduates of foreign medical schools, many of whom have been trained in innovative pedagogical systems costing far less and providing skills more calibrated to today’s health care system needs. But given the heavy annual investment our nation makes in training its physicians—$3.3 billion dollars last year through Medicare alone—is this really the outcome that U.S. medical schools are seeking to achieve? A world where medical schools exist to train highly paid specialists, rather than general practitioners?

Medical education must take a deeper look at the radical reforms occurring in higher education. Online degree programs at colleges such as Southern New Hampshire University and Arizona State University have demonstrated that blending a significant amount of online education with more traditional lectures and face-to-face teaching is both effective and acceptable to learners. And while freely available massive open online learning courses, or MOOCs, such as those offered through Coursera have been disparaged for their purportedly high dropout rates, the students who remain—usually those motivated to achieve a certificate and gain entrance to a more traditional curriculum—demonstrate that this type of learning can be both high-tech and high-touch. From the provider’s end, these courses prove very cost effective in the long run, particularly as the number of students per course rises with minimal additional cost to the school.

How can these lessons be applied to medical education? Despite a flurry of curricular reforms in the past 10 years medical school has changed little over the last century. Students spend the first phase of the curriculum, usually 18-24 months, in the classroom absorbing a staggering amount of medical knowledge from a large team of basic science faculty. Funding streams for these salaries, traditionally through research grant dollars, are now drying up and leaving medical schools to bear a growing share of these costs.

During this first phase, students also learn the fundamentals of patient care from busy physicians who take time out of their pressured clinical schedule to travel to the medical school—another cost borne by the school and its affiliated academic health center.

In the second and clinical phase of the curriculum, students rotate through the standard medical disciplines—surgery, medicine, pediatrics, family medicine, OBGYN, psychiatry, neurology—caring for patients in a team with residents and clinical teaching faculty. These rotations are most frequently concentrated at costly academic health centers in large urban areas, with students and residents elbowing each other for the limited teaching time provided by busy clinical faculty—leaving much of the student’s education provided by the residents themselves, with variable efficacy.

Presently, the high cost of a medical education rises partly from the need to spend four years in a brick-and-mortar system. Given that the first 18 months of medical school is essentially the same for 18,000 students at 150 medical schools, why must 150 different professors teach the same basic science content at the exact same time? Haven’t the MOOCs shown us that this type of learning can be accomplished far more efficiently, and be just as effective, online?

These types of experiments have started in a few schools: In one collaboration funded by the Robert Wood Johnson Foundation, the Khan Academy, Stanford School of Medicine, and four other medical schools are delivering a single online immunology course to students at all five institutions. Like a MOOC, these online courses show the same promise of consistent and high-quality content, adaptive learning, and the ability to track student’s progress at a more data-driven level than classroom learning.

Despite the promise of the Affordable Care Act, physician compensation practices remain tethered to the provision of treatment, not the maintenance of health, thus rewarding higher volumes of patients seen and procedures performed.

Ultimately, training a physician is not a classroom-based activity. It requires highly skilled clinician teachers working side-by-side with students to provide hands-on patient care. Can online education play a role here as well?

MedU, the non-profit medical education organization that I co-founded in 2006, provides online clinical learning to 98 percent of today’s medical students. Through collaborations with other leading medical education organizations, 30,0000 students learn from over 1,000,000 virtual patient sessions annually. These courses cost the medical school a fraction of what a physician-led lecture series would cost.

Further, MedU lets medical schools place students outside of traditional academic health centers and into community-based, rural, and underserved areas for their clinical preceptorships. Not only does this often cost the school far less than a traditional placement, it opens up a relatively unlimited supply of patients and physician teachers across the nation practicing and teaching the type of everyday medicine that should be a priority to our best and brightest.

Clay Christenson’s work reminds us that significantly disruptive changes begin at the margin and move to the mainstream as they gain efficiencies and effectiveness. A public medical school in an underserved state, struggling to find the public dollars to train a physician workforce (often comprised of underserved minorities themselves), may well be eager to employ a new model that would educate those physicians just as well for half the cost.

One can envision a new system whereby students enroll at a very limited cost in a national MOOC that provides the basic science curriculum which could be taken at their own pace. This could allow more underserved students to work, paying as they go. Affiliated clinical skills such as venipuncture and EMT training may even allow an alternative paying career for those who do not ultimately make the grade.

Students would be admitted to the clinical, and more costly, curriculum only after passing their first board exam. Once admitted, students would come together initially in a series of intense face-to-face sessions on clinical skills, and then be disseminated to lower cost community-based training sites, supported by an online curriculum delivered and monitored centrally by the medical school, returning to campus intermittently for courses best taught face-to-face. Faculty development for these new community sites could also easily be done online.

While the current curriculum reforms in medical education are making great strides, ultimately they are no more than the proverbial moving of deck chairs around on the Titanic. And our students—and by extension the health of our nation’s population—are the ones who will ultimately drown without a significant course correction. Currently, the iceberg remains dead ahead.