Medical School: A Whistleblower's Story
By Bryan Caplan
Here’s an email from a former medical student who heard my EconTalk with Russ Roberts. Reprinted anonymously with his permission.
Good afternoon Drs. Caplan and Roberts,
My name is [redacted] and I recently listened to your conversation on Econtalk regarding education. I wanted to pick your brains regarding the structure and finance of medical education in the US.
I recently left medical school after one semester. I spent years and thousands of dollars on tuition, preparing and taking the MCAT, applying to medical school, going on interviews, etc. Ultimately I came to the decision that my heart wasn’t 100% in medicine and I was unwilling to pay the opportunity costs.
I’ve actually applied to anesthesiologist assistant (AA) programs, which are just two years in length. AAs legally must work under the supervision of a physician anesthesiologist and they essentially function like physician assistants, but are specific to anesthesia.
This got me thinking about the practice of medicine and the scope of practice issues that have come up in the last few decades across state legislatures. I am not an economist by any means, though I definitely wish I took more econ courses in college. I even though about grad school in public policy but that’s a conversation for another time.
I’m not sure if any of your research has addressed the topic of medical education or not. I’ve heard the American Medical Association referred to as a cartel in another podcast, Freakonomics.* I think the episode was discussing the role of nurse practitioners which has made some primary care physicians uncomfortable.
Specific to anesthesia has been the ongoing battle between certified registered nurse anesthetists (CRNAs) and anesthesiologist assistants, who have actually been around for over 40 years. According to legal precedents, anesthesia is considered both a nursing specialty as well as a medical speciality. The CRNA lobby is phenomenally politically savvy and they have
blocked legislation for AAs to work in various states. Currently, AAs are only allowed to practice in 18 states. Of course the irony is not lost upon me since the very same arguments CRNAs use against AAs are the same ones physicians have used against other mid-levels.
Having worked in healthcare prior to med school, I was able to see the enormous financial decisions that go into patient care. There are clearly external forces influencing behavioral â€‹decision making, from C-suite executives to physicians-in-training.
As an intellectual exercise, I’ve often pondered about the state of medical education in the US. Nowhere else in the world are medical students required to attend college for four years before matriculating into medical school. The so-called Hopkins model has been championed by the Flexner Report of 1910 and we apparently still think it’s the only appropriate pedagogical model to train the next generation of physicians.
Perhaps it was one of the major reasons why I left med school. The constant testing and ineffective teaching strategies left much to be desired, particularly for long-term retention. Even the licensing schedule that has developed through the years has become cumbersome: Step 1, Step 2 (which has two parts), and Step 3. This does not include the exams you take in your actual specialty once you finish residency. Each exam can cost thousands of dollars, not including preparation materials that help you pass the tests.
The argument for all of this testing is always in the name of “patient safety” and to “protect the public.” I think it also serves to exclude others who would otherwise try to practice medicine.
I question the sustainability of this system. Billions of dollars pour in from Medicare to fund graduate medical education and yet we’re still projected to have a physician shortage. To be fair, I have also read research indicating it’s not so much a shortage of physicians as it is a maldistribution of physicians. I think physicians are trying to have their cake and eat it too:
restricting other providers’ scope of practice while simultaneously refusing to practice medicine in underserved areas. I see the issue of medical education as both a public policy concern as well as a curricular one. Yes, the curriculum is rigid and doesn’t reflect the advances made in technology and learning sciences. It’s also incredibly expensive. Some med schools charge out-of-state tuition upwards of $60,000 for ONE year. Where the money goes, I have no idea. I think if you cut out the mandatory baccalaureate degree, people would be able to save time and money. Most other countries allow students to begin medical studies right after high school.
My sister is a high school sophomore and I’m trying to steer her in the right direction so she doesn’t make the same mistakes I did. My parents are immigrants from Vietnam and neither of them have a college education. We were always told to go to college and the hard work will pay off in the future. That piece of paper will mean something. And then 2008 hit and things changed. I see the proliferation of meaningless master’s degrees and a certification test for X, Y, Z field. I don’t think this rampant obsession with credentialism actually brings forth any value though.
As economists, what are your thoughts on the state of American healthcare? Do you think more healthcare providers makes economic sense or does it endanger patient safety?
* A similar discussion occurred in this EconTalk episode with historian Christy Ford Chapin.