The world needs more physicians. Increasing their numbers alone won’t solve the many problems associated with improving health care. But it doesn’t help to have a dearth of doctors, who were generally in short supply before COVID-19 struck. The pandemic has only exacerbated doctor shortages everywhere. This doesn’t bode well for a world that must prepare for future pandemics and for populations that are both growing and aging. Better health outcomes require more physicians. So, where are the bottlenecks?
Physician training takes different tracks in different countries. The United States has the longest and most expensive medical education system in the developed world. Many facets of this system have been criticized, from the financial burden to the requisite 12 years of education and training, not to mention the intense competition to enter this career track. A US medical education requires 4 years of undergraduate studies and 4 years of medical school, whereas in most European countries, students can accomplish this in 6 years. Recently on this page, it was argued that the US pre–medical school (premed) curriculum should be reconsidered by medical schools and medical regulatory bodies. One question addressed the degree to which all undergraduates who pursue science and medicine require science courses of the same breadth and depth. For example, the content in the customary introductory four-semester chemistry sequence is highly relevant for future practicing chemists. But which units are essential for future medical professionals? Of course, some premed students major in chemistry, but does one chemistry track optimally serve all? Reconfiguring the science requirements for premed students might go a long way in attracting—and keeping—students in the physician pipeline.
When analyzing curriculum and policy issues in US academia, there can be a tendency to overlook practices in other countries. I’ve taught organic chemistry at all levels in the United States and Germany (Universität Erlangen–Nürnberg). The German premed students directly matriculate into medical schools on the basis of a post–secondary school exam. Unlike their US counterparts, they do not declare subject “majors.” Rather, they take the same standardized 2-year preclinical curriculum. This culminates with a comprehensive “state exam” that lasts 2 or more days, which must be passed to advance to clinical training. In stark contrast to US practices, the premed students in Germany are only required to take one semester of a combined general and organic chemistry course, a single laboratory course, and (at Erlangen) one final exam that is graded as pass/fail (typically 85 ± 5% passing). Thus, what would take four semesters in the United States is condensed to a single semester in Germany (further biochemistry is required in subsequent preclinical semesters). Other European countries have different practices, but none require the depth and breadth of chemistry that is customary in the United States.
Given the successful operation of streamlined science tracks outside the United States, and an absence of data suggesting that less qualified physicians are produced as a result, what factors anchor the US status quo? The medical school at Texas A&M University, for example, requires two semesters of both general and organic chemistry (all including a laboratory) as well as biochemistry. There have been experiments with shortened versions of the four-semester sequence at several US universities, but this wouldn’t suffice for admission into Texas A&M’s medical school. Compounding this gridlock, the lines of communication to medical schools and examination boards regarding optimal “learning outcomes” for future generations of doctors are broken. To cut this Gordian knot and help increase the number of doctors and much needed clinics and hospitals, a high-profile forum is urgently needed in which all the constituents of the doctor-producing pipeline rethink premedical education. Otherwise, substantive modernization and the rational development of widely accepted alternative tracks will never be possible.
One overarching issue remains: Around the globe, students in premedical curricula face intense pressure both inside and outside the classroom and are often highly stressed. This leads to mental health difficulties and student attrition, consequences that could be ameliorated with renewed attention to program and pedagogy. To disregard this is collective malpractice that further constricts the bottleneck for producing the medical professionals that the world so desperately needs.
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