Column: Preclinical medical education is wastefully obsolete

Editor's Note: This article was written and originally published on October 2, 2017. No changes have been made since the date of publication.

The preclinical years of medical education are a scam. 

Undergraduate medical education in America (i.e., the period of medical school before graduating with an M.D. degree) is generally split into two years in the classroom and two years seeing patients in the clinic. This system was recommended by the Flexner Report more than a century ago, and it is a thorough blueprint for ensuring students learn the science and skill of medicine, respectively. Developments in self-study resources and medical curriculum norms, though, have made the price of the preclinical semesters absurd. The National Board of Medical Examiners should test — and medical schools should welcome — those who want to jump right into clinical studies.

An independent academic resource like UWorld, a computer, a couple hundred dollars for a year-long subscription and internet access can provide thousands of practice questions and detailed explanations of all crucial medical science concepts. I don’t write this lightly — I’m deeply thankful to the wonderful medical science professors I learn from at the UNC School of Medicine — but such resources make the classroom portion of medical school obsolete. Question banks are a superior way to learn medical science.

Don’t just take my word for it: studies like this one and this one support the idea that practicing retrieval (e.g. doing a heap of practice questions) is a better way to promote long-term learning than simply studying material. Classroom teaching, to the extent that it focuses on exposing students to information repeatedly and not on testing them, is not only much more expensive than learning through practice questions: it's a poor way to ingrain knowledge.

Obviously, everyone has to be exposed to material at least once before cementing it in memory with practice questions. Personally, I find UWorld’s explanations sufficient for this first exposure, but even students who want lecture-like presentation of medical knowledge don’t need to pay for medical school lectures: free resources like Khan Academy can fill that gap. 

Of course, even if traditional preclinical medical education isn’t the most efficient option for knowledge acquisition, there could be other reasons it's worth the cost.

It’s conceivable, for example, that preclinical classroom time is mainly about acculturation. After all, spending time learning from medical role models is likely to have a big influence on students, like me, but if this were the main purpose of the preclinical years, they could still be omitted without much harm. My cohort and I will have plenty of time to absorb professional values from doctors in what will be our third and fourth years (or clinical years) of medical school. 

It would also once have been plausible, too, to argue that the classroom portion of the preclinical years are necessary as a further test of medical students’ diligence. Good attendance and grades in the preclinical years, clearly, have the potential to show residency programs (post-graduate medical education) that a student knows how to show up and work hard. Now, though, the current grading system for preclinical years at most medical schools is pass/fail, and attendance for lectures is often optional, too. 

What this adds up to is that the board exam which medical students take at the end of their preclinical time, known as Step 1, is basically the only thing residency programs look at to judge academic readiness. As far as post-graduate placement goes, a traditional preclinical medical student and a self-study-only preclinical medical student with the same board score would look nearly identical on paper (if the latter were allowed to take that board exam outside the auspices of a traditional medical school).

Despite all this, one can still make the case that preclinical year classroom experiences are important for medical students, pointing out that such shared time builds important community and relationships between students. Indeed, I find this the most compelling argument in favor of classroom preclinical time. It’s just not strong enough to merit the cost of that time on its own. 

Because that cost is high. Take the UNC School of Medicine, for example. Its tuition for in-state residents, $13,818.50 a semester for 2017-2018, is less than average. Moreover, a few years ago, UNC shortened its preclinical curriculum from two years to a year and a half. And, during those 18 months, the curriculum includes one course in clinical skills. But even taking all those things into account, my conservative estimate is that a UNC medical student wastes more than $30,000 in tuition during his or her preclinical education. Multiply that by 180 students per year, and you get more than five million dollars wasted per class. 

For many students, $30,000 saved would mean less student debt, which might lead them to pick a more needed medical vocation later on, rather than a more lucrative specialty. Crudely put, more family medicine doctors churned out, less dermatologists. That’s an important benefit to reducing money wasted on tuition — but it’s pretty dry-sounding.

A more sensational way to illustrate what $30,000 saved might mean is to frame it in terms of life-saving potential: philanthropy watchdog GiveWell calculated in 2015 that $3,337 donated to the (mosquito net charity) Against Malaria Foundation equals one life preserved. 

So a medical student who saved $30,000 could theoretically save nine lives with that money before they ever got to the clinic. For any future doctor, that’s quite a head start. 

While medical education is a complicated issue, preclinical education shouldn’t be. Let people study on their own, take Step 1 independent of affiliation with a medical school and apply to enter directly into the clinical years of medical education.

The money saved — and debt avoided — could do a lot of good.