Should doctors specialize earlier in their education?

Great Debates
1

As I read about the health care debate, I wonder if our conception of doctors needs to change. As a lawyer, I know that my field’s method of education is somewhat inefficient. We receive three years of expensive general training, after which we are barely competent to actually practice in most areas of law, and often the field in which we do practice doesn’t require knowledge of all the areas of law we spent years becoming minimally competent in.

And from what I know of med school, doctors have it even worse than lawyers. While lawyers are certified to go practice before they’ve performed the equivalent of their residencies (and thus get paid while they actually learn how to practice), doctors spend years getting shit pay while they finish their educations.

From what little I know about the education of engineers, I can’t help wondering whether that isn’t a better model.

So my question is this: Given the high costs of years of schooling (and the pernicious effects of debt on the field), should the way we change the way we educate doctors to make their training more efficient and focused? Or is medicine so inherently interdisciplinary that the vast majority of doctors need that broad background?

2

Good question.

I chose Engineering myself because I could actually be a useful engineer in a shorter time than I could be a useful doctor (“useful” being a subjective term, of course). I didn’t know at the time why it was a shorter period, but your question probably describes it. I ended up with 2 BS’s (4 yrs), no further. Our education was 2 years general sciences, 2 years specific to our field (though Electrical Engineering is actually still very broad, including circuits, radio, and programming, among others).

I find the knowledge of chemistry that I gained in the first two years to be quite interesting and fun. But, as a programmer, I do not find it to be useful. Similarly with physics, statics & dynamics, and even semiconductors and circuits. I feel that if I had gone directly for a programming degree (say, CS), I wouldn’t have had as many options – I’d have been railroaded into a single career, whereas I could probably make the shift into hardware design even now – 10 years later – much more easily than someone without my breadth.

So, for myself, I’m happy that I have the breadth for both fun and options. And yet, at the same time, in hindsight, I sure think that some of the courses were unnecessary. If I’d only taken the courses that gave information I’ve used since graduation, I’m pretty sure I could have been done in 2 years or less instead of 4. Having an extra two years of earnings, and being less 2 years of college expenses would be wonderful for my pocketbook.

Would my clients (the corporations that hire me) be unhappy that I was lacking all of that background? No. CS guys get paid just as much as I do for programming – which means both that my extra EE knowledge is unnecessary to employers and so is the extra CS knowledge that goes beyond what I have. It’s a different specialty, yes, but when someone in the office has a hardware question, I can help, and when I have a high-level software question, I ask someone else.

All of this is in engineering, rather than medicine, of course, but I believe that it applies. A general practice doctor needs enough understanding to tell you which specialist to see, but that’s all. And a specialist need only know about his specific field. There should be some overlap (podiatrists should have some knowledge of dermatology), but it needn’t be extreme.

I, personally, wouldn’t mind having a doctor who had less breadth of knowledge, if it meant that I had to pay less to see him. It means that I would then be able to afford to see the specialist he recommends, which is far preferable to getting the generalist to solve the problem himself, since he can’t possibly know everything there is to know about the human body and the diagnoses thereof.

And if medical school were less expensive (in terms of time and money), I believe we’d find more people, like myself, who choose it, lowering costs for consumers even more.

3

What about primary care providers? Will there be a “little bit of everything” track? Who is going to orchestrate the show?

Unlike in law or engineering, or at least to a greater extent, every organ system is vitally connected with the rest of the body, and considering one organ/organ system requires considering the inputs from and effects on the rest of the person. A judge presiding over criminal trials probably doesn’t give a hoot about, say, tax law, unless someone comes in before him for tax evasion. A doctor doesn’t have the luxury of ignoring the rest of the body until it becomes a crisis.

E.g., you can’t, say, do orthopedic surgery without considering the effects on the rest of the person – they may have a metabolic disorder that weakened their bones and caused them to fracture their leg, they may be on blood thinners for heart disease that will affect either the timing of the surgery (wait to withdraw from blood thinners, if you consider it safe for their heart) or the likelihood of bleeding complications, and there may be a neurologic problem that caused them to fall and break their leg. This just skims the surface – then there’s the consideration of the effects of anesthesia; the status of the rest of the person’s body may affect whether general anesthesia is used or just a spinal or epidural block, as well as how the person weathers anesthesia.

When it comes to diagnosis, it’s not always clear cut what type of doctor you need: many diseases affect multiple organ systems and/or mimic completely different diseases. Along these lines, there is a tendency among specialists to “see” something in their specialty as being at the top of the list of possibilities, simply because they have seen that something many times and are familiar with it. I’m sure there’s a name for this cognitive bias, but I’m not sure what it is. If the specialists knew even less about other systems, how likely would they be to recognize that the patient’s problem is not “X” in their specialty, but actually “Z” in someone else’s specialty, even though “X” and “Z” present very similarly?

That said, I have seen med students complain that they are required to learn too MUCH detail about obscure material that they will either a) not need in their chosen specialty or b) learn about in much greater detail anyway during residency and fellowship. Maybe there’s a compromise to be made – still have students rotate through specialties to get perspective on what their colleagues deal with and select what specialty they like, but cut some of the detail out of the classroom work.

4

The question you’re really asking is: could we train doctors less than we currently do? And I would say no: doctors need to have that knowledge to function fully as professionals. I could see them deciding to be doctors earlier in their career, as is done in the Commonwealth system of 6-year combined college and medical school, but that’s a function of undergraduate colleges, not medical school.

And what do you mean by the “pernicious effects of debt on the field”?

5

He probably means the extreme decline in general practitioners while many go to pursue more lucrative specializations like plastic surgery or dermatology. If you’re riddled with debt, few new doctors are going to want to go where the real need is (GP) if there is no real money there.

6

That seems more of a problem of reimbursement for GPs. (Of course that’s the problem with Medicare setting rates like a central planner: as long as you undercharge for GP services you’ll have a shortage of GPs. A market (which is unlikely to emerge under either party’s plans) would bid up rates until supply equaled demand.) Or, to put it differently, the fact that we refuse to pay GPs more shows that we’re not really serious about there being a problematic shortage of primary care doctors. Unless we put our money where our mouths are, talk of overspecializing is so much twaddle; we clearly value specialists more at the margin.

7

horsetech:

Is it true that some doctors need to be experts at all things human body? Other than emergencies, it seems like there’s always time for collaboration. And emergency medicine is itself a delineated field of medicine in which you need to know certain things and not others.

There also seems (and I’m speaking largely from ignorance here) to be overlap between doctors on a course to do research and those on a course for clinical practice. Does any primary care physician need to be an expert in organic chemistry?

The construction of a new building requires electrical engineers, materials engineers, civil engineers, etc. Lives are in the balance. But we don’t say that there has to be one guy who understands the whole system.

athelas:

The problem with your market analysis is that neither the requirements and certifications for becoming an MD nor the amount that doctors are paid are governed by the market. The former is entirely a decision of state governments, and the latter a complex amalgam of government decisions and poorly-functioning semi-markets.

8

Yeah, that’s why I said that positing a free market was impractical. Still, the persistent cries about primary care shortages does point up how unfree the current system is.

9

I’m not convinced there can ever be a well-functioning market in medicine because of the nature of doctors and patients as providers and consumers, but that’s another debate altogether. For the purposes of this one, I think we can safely presume that if we can reduce the cost of doctor’s educations without sacrificing care, that would be a good thing.

I was sort of hoping to hear from various doctors about whether they call upon all of their generalist training in their current roles, but I guess this board needs to trade a few of its lawyers for doctors.

10

I believe that the first three years of medical school are necessary for any doctor. The first two years are spent in the classroom, learning the normal and abnormal function of the body. I really don’t think this could be cut down any.

The third year is spent rotating through the various specialties, usually a month at a time. This is important for general knowledge purposes, but also because most of the people in my class didn’t really decide what they wanted to do until they were well into their third year.

If there’s any fat to be trimmed in med school, it’s in the fourth year. Usually there are a couple of months of acting internship, a small handful of requirements, and a whole bunch of electives, all loosely spaced to allow time for residency interviews. I thought it was a wonderful bit of downtime in between hellish stretches, but the actual amount of learning that happened that year was pretty slim.

In fact, my medical school had a “3+3” program for students going into IM or FP that basically combined the last year of med school and the first year of internship. (I didn’t do it because I wanted to go somewhere else for residency.)

I’m not sure residency could be shortened. I’m only really familiar with IM (which I did) and FP (where I teach), but three years seems about right for them.

The only question left is whether a four-year degree should be de facto required for med school admission. (At least when I was applying, it wasn’t technically required, but might as well have been.) I think it’s better to have a stronger academic base before starting med school, but so many people go through undergrad with a singleminded focus on med school that it probably doesn’t make that much difference.

So in the end, yeah, I think you could probably shave a year or two off of a medical education, but I’m glad I didn’t.

11

DoctorJ, I forgot that med school was 2 + 2, since most vet schools are 3 classroom + 1 clinical. :smack:

Richard Parker, maybe the question of collaboration is part of the problem. What part of the current system encourages collaboration? The primary care provider is the only one, at best, who besides the patient knows which specialists they are seeing and for what.

Hopefully, DoctorJ, having bona fide experience (N.B.: I am merely a fascinated outsider, working on becoming an insider of the veterinary medical community), can comment more on this, but my impression is that the primary care provider has to know about everything so that they can at the very least start the work-up and point the patient in the right direction. Similar with the emergency provider, who has to rule out immediately life-threatening disease, which includes not just the obvious bleeding out/heart attack but also somewhat obscure catastrophic failure of any body system. These are both specialties cultivated AFTER medical school.

OK, I’m pretty ignorant of engineering, so I’m going to try to extend the building analogy, and you can tell me where I get something wrong or go off the deep end. If the electrical engineer screws up the wiring scheme of the building, obviously the gestalt breaks down and the building is not exactly usable. But it is obvious that it is an electrical engineering problem, right? And the electrical engineer has to fix it, right? If the building were a human body, a problem with the electrical system would also cause all of the third floor balconies to fall off, and rearrange the seventh floor so that no one could find the bathroom, and make some of the wood rot, and you’d need to be able to figure out whether it was actually the fault of the electrical engineer or if the wood started to rot and then THAT made the electricity go wrong, hid the toilets, and did in the balconies.

I agree, it would be helpful if some other doctors (and even veterinarians) weighed in.

RE: becoming experts on things such as organic chemistry:

My WAG is that, no, a PCP does not need to become an EXPERT on organic chemistry, but being exposed to it helps put into perspective (and therefore make easier to understand, generalize, and predict) issues such as receptor specificity and exogenous analogues and pretty much all of pharmacology. Basic inorganic chemistry is important for understanding acid-base and electrolyte disturbances. Even though I remember only a small fraction of what I “learned” in organic chemistry, having taken it makes it easier for me to understand, say, articles/chapters (nerd alert, I read everything I can get my hands on about medicine for any species when I’m not on the Dope) about patterns of cross-resistance to antibiotics, or how to roughly predict based on structure which drugs will cross the blood-brain barrier and which ones won’t.

I would take the comments on GPs’ financial situations one step further and say that the health care system is shooting itself in the foot, in the long run, by monetarily rewarding procedures at the expense of cognitive-based specialties.

12

First off by way of an aside is something some med school professor said to our class early on:

“Half of what you learn in medical school will be obsolete in ten years. You’ll forget half of what you learn in medical school. Just make sure they’re the same half.”

Much of what I learned in the basic years was not necessary for my clinical life. Do I really need to know how to utilize a particular drug’s volume of distribution and half life? Or will I actually just look up its proper dosing intervals? Did I really need to memorize all those tuberosities and attachements? Or be able to identify all those histopath slides? What there is to know has gotten to be so huge that even the smartest in my class can only hope to know a small fraction of “normal and abnormal function of the body.” In fact the attempt to cram more and more facts into us in the same amount of time increasingly makes it such that we really understand less and less and have less and less time to critically evaluate that which we learn or to hone our critical thinking skills. That which gets called “evidence-based medicine” often turns into anything but our critical evaluation of evidence and instead is the recitation of the conclusions of guideline committees. The wisest in my medical school class knew less than the smartest one did; the difference was that he knew how much he didn’t know, and knew how to manage that information - critically accessing it when he needed it through a variety of resources.

I disagree with you, Doctor J that those first years are needed in order to teach the normal and abnormal function. That goal is a fool’s errand, IMHO. Yet I agree strongly that those years cannot be cut down. I would just like to see less emphasis on trying to cram several tomes of unrelated facts into a limited volume of grey matter, and more on being critical consumers of scientific information, on honing the tools needed to understand and evaluate advances that are yet to be.

I concur about the importance of the clinical rotations although I place more value on year four than you do. I just don’t think that someone is ready to be an intern by the end of third year. The rotations can be of special interest but the additional clinical experience gets them ready to function on the floor.

And I feel more strongly about the value of the undergraduate years, and in particular a decent liberal arts base, more than organic chemistry (although I really did enjoy it … seriously … they were fun puzzles to solve). Doctors are best if they are both good critical thinkers and effective communicators. A solid liberal arts education helps them to develop those skills. Doctors are less than optimal when they are merely skillful technicians.

So in the end, no, I don’t think you could shave off much time, not without significantly sacrificing the quality of the product. But I think the time could be spent much more wisely than it currently is.

IMHO that is.

13

In ten years, expert systems might be ‘good enough’ that most doctors won’t have to know the basics of things. Maybe. A ‘technican’ class of doctor could emerge, a new kind of GP. Much cheaper than the normal kind, and we do need them.

14

What is it about dentistry that allowed them to spin-off into a standalone field, whereas a podiatrist could not do this?

15

They are.

Podiatric medicine is not a medical specialty in the way that OB/GYN, Family, Pediatrics, or Surgery is.

They are DPM’s; Doctor of Podiatric Medicine, not MD’s.

I’ll try to be back to contribute more to this thread later.

16

Well, how about that? :slight_smile:

So what other types of doctoring have been stripped away? Radiologists? Optometrists? Dermatologists? If everything is connected to everything else, what distinguishes dentists and podiatrists from the rest of them?

17

Optometrists are ODs, not MDs. Opthalmologists are MDs, as are radiologists, dermatologists, anesthesiologists (except when the MDs are DOs, of course. but that’s a topic for another thread).

Podiatry school, optometry school, and dental school focus pretty much on the anatomy, physiology, pathology and treatment of those specific areas, with some basic overall pathophysiology, pharmacology, etc. thrown in. Graduate from one of these schools, and you’re prepared to practice that particular specialty, and nothing but that specialty.

Medical school (for MD and DO) gives general medical training for the body as a whole, and until just a few decades ago, graduating with a medical degree was sufficient to let a person go out and practice general medicine. (Now post-grad work is required to get a license to do so).

Specializing early is great if a person really, really knows what specialty they want. But that can change very quickly at any point during the education. A good friend of mine in college & med school knew he was going to be a cardiac surgeon, absolutely no doubt. But late in his 3rd year of med school, he shocked everyone (especially the cardiac surgery department, to whom he’d been the apple of their eye) when he announced he was going into internal medicine, and eventually chose infectious disease.

I myself didn’t commit to a specialty (family medicine) until late in my 3rd year, having been undecided until then.

I think what’s needed is more affordable medical school, so students don’t come out half a million dollars in debt (which definitely can influence specialty choice). Add to this a more equitable reimbursement system that pays generalists competitive rates (and a competent FP or internist can take care of well over 90% of his/her patients without the need to refer) while de-emphasizing the whole “pay for procedure” aspect to medicine which rewards the docs who do surgeries, colonoscopies, etc with much higher reimbursement rates per hour than the doc who’s “only” listening to and examining the patient.

18

What you are describing sounds a lot like a Physician Assistant to me.

19

Yes, quite so, but more so. More independent, capable of working as the old Family Doctor, and referring people to specialists as needed, accurately. We do need some class of doctors capable of giving preventive care at a lower price and greater volume… we just don’t have enough of the modern ‘needs postgrad education’ GPs to do the job.

20

Could med school start earlier? Nearly everyone gets a 4-year degree before starting med school, and I understand that most schools now require it, but this wasn’t always the case. How are physicians trained in other countries?