Habib Dakik reflects on changes to the US medical school cirriculum, and the potential implications of such changes elsewhere.

There have been major calls for a revision of the medical school curriculum in the United States in the recent years (1-3). This is driven by several factors one of which is the major advancements in information technology and the increased adoption of students of self-study and online education. Although these calls are primarily in the US, they will have a much wider impact, given its international impact on medical education.

Surveys in the US have indicated that a substantial percentage of students do not attend in-person classes in the preclinical years, they instead rely on pre-recorded lectures from their own institutions or from multiple available commercial sources (4). Although this has been portrayed as a student choice, faculty members themselves may be pushing indirectly for this as well. With the increasing pressure of clinical duties, many clinical faculty (who are significantly involved in medical education) have found it more “time effective” to record their lectures and have it available for students rather than taking time from their clinical services to deliver these lectures in person. This applies to PhD professors as well who teach the basic sciences in preclinical years and also have busy research programs, thus finding an attractive option in prerecorded lectures.  This raises an important issue related to the overlap of education, clinical service, and research in medical schools. Traditionally, medical schools were built as the center of academic medical centers with hospitals and research centers built around them to support their mission. This has been changing slowly over the years due to financial pressures whereby clinical services are becoming the core of academic medical centers. As a matter of fact, large medical centers are sometimes being built first, primarily to provide clinical services, and later on they would open medical schools and research centers to add academic value to their operations.  Although there have been a lot of effort and resources placed to refocus on education and try to build “core teaching faculty” with protected time to support the teaching mission, the reality remains that the best teachers are many times those who are excellent researchers or those who are excellent clinicians with busy practices. Therefore, calls for revision of medical school curriculum have to go hand in hand with a closer look at the clinical and research missions of academic medical centers.

For medical students outside the US, Europe, and the United Kingdom a major reason for swaying away from in-person lectures is the pressure to pass the qualifying exams and being able to get residency slots abroad. That is why many of those medical students follow two curricula at the same time: that of their medical school to pass its own exams and a “parallel curriculum” using multiple online resources that are focused primarily on passing these qualifying exams with high scores. Although the new USMLE part I exam required in the US is now a pass /fail test, the USMLE part II and other tests required in Europe and the UK remain scored. Due to the constraints of time, students often have to choose between these two curricula, and most of the times they choose the one focusing on these qualifying exams. This effect does not stop at the preclinical years but carries on to the clinical years where although students are required physically to be present in the hospital and on rounds, in reality they are mentally totally pre-occupied with these exams, which make them compromise on essential clinical training skills.

Another important factor when considering the revision of medical school curriculum is age. The mean age of students entering US medical schools is 24 years (5). Many of those students take some time off after undergraduate school to work or get a master’s degree during which they acquire many essential habits related to self-study and self-work. Therefore, they become more mature and able to adopt a self-study curriculum during medical school. This might not be the case for students in other countries.  In Lebanon for example, the vast majority of medical students enter medical school immediately after finishing a 3-year undergraduate degree, which they would have enrolled in immediately after finishing high school. Thus, their mean age would be around 3 years younger than their US colleagues. Those students might not be able to fully comprehend a self-directed curriculum and will probably need more structured learning with regularly scheduled in-person interactions in lectures and small group discussions.

There is no doubt that the medical school curriculum will have to evolve and be revised to accommodate the new advances in information technology and the behavioral changes in medical students learning. The changes in the US medical education system will have worldwide implications but will probably need to be re-examined and fine-tuned in other countries to adjust for other logistic and cultural elements. In some of these places, structured in-person lectures / discussions might still need to remain the backbone of medical education with supplementation from other online resources.

References

1. Wu JH, Gruppuso PA, Adashi EY. The Self-directed Medical Student Curriculum. JAMA. 2021 Nov 23;326(20):2005-2006. doi: 10.1001/jama.2021.16312.
2. Emanuel EJ. The Inevitable Reimagining of Medical Education. JAMA. 2020 Mar 24;323(12):1127-1128. doi: 10.1001/jama.2020.1227.
3. Stoddard HA. Reconfiguring Medical Education. JAMA. 2020 Sep 8;324(10):1005-1006. doi: 10.1001/jama.2020.10899.
4. Association of American Medical Colleges. Medical education: year two questionnaire (Y2Q). Accessed November 28, 2021. https://www.aamc.org/data-reports/students-residents/report/year-two-questionnaire-y2q.
5. Association of American Medical Colleges. Age of Applicants to U.S. Medical Schools at Anticipated Matriculation. Accessed November 28, 2021. https://www.aamc.org/system/files/d/1/321468-factstablea6.pdf

Dr. Habib Dakik is Tenured Professor of Medicine and Chief of Cardiology at the American University of Beirut Medical Center, Lebanon. He received his BS and MD degrees from the American University of Beirut and completed clinical training in Internal Medicine and Cardiology at Baylor College of Medicine, Houston, Texas, USA