Tuesday, April 13, 2010

A 3 Year Medical School in Texas

In order to ease the critical shortage of primary care physicians, Texas Tech School of Medicine is starting a pilot program which streamlines medical school to a 3 year program for students committed to primary care medicine.

This is an interesting model, and one which I think can be applied to psychiatry as well, since
the shortage of psychiatrists is nearly as acute as the shortage of family practitioners. We could create a special track for future psychiatrists which would include early courses in psychotherapy and psychopharmacology, omitting courses of less relevance to our field.

USA Today covers this topic nicely here as well. It turns out many other medical schools are considering similar programs.

17 comments:

Anonymous said...

There was a program where I went to medical school that would let 4th year medical students start their internship in Family Practice if they were admitted to the program. In essence, the 4th year of medical school would be their first year of the family practice residency, thereby effectively shortening medical school to 3 years. I think this model could work in other fields as well (ie 4th year actually is the internship in your chosen field).

I do think it is bizarre that students are asked to make these decisions about their future field of medicine without really knowing much about the field (in some cases students may have had only 2-4 weeks exposure).

Ronald Pies MD said...

The idea of a 3-year medical school curriculum is a worthy one, Danny--as we have discussed, and as I advocate on the "studentdoctor" website where we exchanged some views. That leaves room for a 5th year in psychiatry residency, in which I would love to see residents enhance their skills in neurology, psychotherapy, and yes--study the humanities, too! --Regards, Ron Pies

SteveM said...

Yeah, but it appears that the academic program is identical. So apparently no courses are omitted. They just knocked out breaks.

Nothing wrong with that. If universally implemented, it would increase M.D. throughput by 25%. But it seems like a trivial adaptation when the residency training is tacked on. I.e., 8 to 10 years of total training is reduced by only a year (10 to 12% duration reduction). Of course residency programs would have to adapt to accommodate the increased Med School throughput.

An obvious question is that if the normative psychiatric residency program is defective and it would take an additional year of residency to fix it, why isn't that additional year being tacked on right now, apart from the M.D. training cycle? Why continue to pump out under-trained psychiatrists?

moviedoc said...

Wouldn't help the shortage of psychiatrists, but if PCP's would stop pretending to be psychiatrists maybe there wouldn't be a shortage of them at least. Not much new here: I finished med school half a year early ~1977 by eliminating summer breaks. What would really help would be a 6 year college + med school program. Don't they do that in Europe? Or why not just let pharmacists take an extra year and let them be PCP's?

Susan said...

I attended a 3 yr. medical school program in chicago from 1973-76. No courses/rotations, etc. were cut out compared to the 4 year class. (There were a few schools that tried the 3 yr. program at that time because of the projected doctor shortage). For me, I would not do it again without modification/streamlining of the curriculum. just too intense, too little time off and since i was already 1 yr. younger than most (just where my birthday fell at kindergarden time), i graduated 2 years younger than average. I was too young really to then go to internship and on- needed more time to "get older" and more mature, especially since all i had ever really done was be a student.

Anonymous said...

My wife graduated from University of Texas School of Medicine in Houston in a 3-year program about 3 decades ago, so this is certainly not a new idea at all.

Stuart Kelter, Psy.D. said...

Dr. Carlat,

The press release for your upcoming book, Unhinged, suggests that you closely identify with many of the criticisms that prescribing psychology has of psychiatry: that psychiatry has given up on all but the biological aspects of human suffering, that the biological underpinnings of psychiatric diagnosis do not in fact rest on solid, scientific ground, that medications are overprescribed, too readily given to children, too often complicated by multiple drugs, and that far too great a percentage of the psychiatric leadership have engaged in corrupt relationships with pharmaceutical companies, in which financial gain for themselves and their profession cloud their judgment as to what is best practice.

Your proposal for what will be a new hybrid profession, which will combine aspects of medical and psychological training within a reasonable length program (five years?), is one possible answer to the shortage of providers. I suspect that you’ll see active resistance only from psychiatrists and other M.D.’s and not by psychologists. The pharmaceutical companies will probably remain neutral, hopeful that the new prescribers will be available to be co-opted, but also apprehensive that curriculum and policies may limit the potential influence of pharmaceutical promotions, CEU materials, and the like.

Please be aware, however, that the psychological aspect of the training will necessarily be limited to something akin to a master’s level training. Moreover, given the tremendous dominance of the medical model in this country, the students could be quite vulnerable to falling under its spell, relegating so-called less scientific aspects of their helping profession (i.e., talking to people about their problems) to a second class status. This is the reason why prescribing psychology decided to restrict psychopharmacology training to licensed psychologists who already have been in the field for a number of years. It takes that long to develop the confidence in one’s identity as a therapist and to hone one’s skill in applying a psychological model to clinical work. The medical model, then, works alongside the psychological one, without supplanting it.

moviedoc said...

Dr. Kelter: Some of the best psychotherapists with whom I have worked, and who trained me, a psychiatrist, had only masters level education, and as you suggest, years of post-graduate training and supervision. Neither PsyD, PhD, or even MD or DO guarantee skill as a psychotherapist.

Stuart Kelter, Psy.D. said...

Dr. Carlat,

I have met people who have more wisdom and counseling skill who have no degree at all. The concern I am raising about the hybrid training model is this: how can students, many of whom will enroll right out of college, balance the medical model of emotional distress with psychological models,with the latter easily dominated by the former. It will take extraordinary leadership and vision to avoid this. For example, if it were up to me, I would not let drug reps in the door of such an educational institution.

Daniel Carlat, M.D. said...

Stuart, I envision a "Doctor of Mental Health" program which would be about 5 years more or less. It would attract students who are interested in the mind, and in learning about all modalities--meds, therapy, ECT, TMS, etc.... Like any graduate program, it would attract a spectrum of applicants, some primarily interested in the medical model, others more interested in therapy, others agnostic to approach.

I assume those who are extremely medically inclined would choose to go to conventional medical school and then psychiatry residency.

This program would not replace psych residencies. Over time, psychiatry will become more and more medical and neurological. It will become a smaller profession of doctors highly specialized in patients whose conditions span medicine, neurology, and psychiatry.

Most patients do not need to see such a hyper-specialist. Doctors of Mental Health would become the major caregiver in the mental health world.

pacificpsych said...

I don't see how this will change the managed care driven 5-15 minute medcheck hell.

NeuroKüz said...

McMaster University in Hamilton, Ontario, Canada, has a progressive 3 year medical school program as well.

Ronald Pies MD said...

Reducing the years of medical school is one thing; ripping psychiatry from the fabric of general medicine is quite another. The two ideas are really very different in nature and implications, and there is real danger in conflating them.

For those who would like to see a different perspective on how psychiatry may need to develop as a profession, there are comments by Dr. Steve Schlozman, as well as my editorial in Psychiatric Times, at:
http://www.psychiatrictimes.com/display/article/10168/1555057

Non-registered viewers are asked to complete a free, brief, registration step, to see the article--but I hope you will take a look.

Best regards,

Ron Pies MD

SteveM said...

I read Dr. Pies’ essay. It’s a lovely mélange of self-congratulation and platitudes, swimming in a rich creamy sauce of selective evasion. All topped with a fat Schlozman cherry of tribal reinforcement. Delicious…

In his essay, Dr. Pies does an adroit dance of anecdotes and fanciful idealistic arm waving to avoid the central issue. I love anecdotes. I love idealism. But what do they have to do with the agreed upon problems with psychiatry? Dr. Pies then outlines a gauzy “prescriptive oath”:

“I accept medical responsibility for your life and health. I affirm that I understand not only the nature of the medication I am giving you, but also the medication’s interaction with your medical and psychiatric diagnoses, physiology, and biochemistry. I affirm that I know the risks of this medication, which, in good faith, I have discussed with you. I also affirm that I know how to manage these risks safely; and that, to the best of my knowledge, these risks are outweighed by this medication’s benefits. I accept that you have placed your faith in me; and your life, in my hands. I am honored by your trust, and, in turn, I trust you to take this medication responsibly.”

And he closes that section with this stern admonition:

“Any clinician who cannot inwardly utter this oath, with confidence and conviction, has no business picking up a prescription pad—whatever the clinician’s profession.”

Well I guess any physician who’s done a 15 minute “med check” should resign and become a hermit. OK, who goes first?

And see this WebMD collection of sad Cymbalta self-reports:

http://www.webmd.com/drugs/drugreview-91491-Cymbalta+Oral.aspx?drugid=91491&drugname=Cymbalta+Oral&conditionFilter=-1

A vast majority of those patients were never warned about Cymbalta side effects by their physicians. If Dr. Pies’ admonition is genuine, then his first action item should be a call for all the physicians who enabled the tens of thousands of Cymbalta human car wrecks close their practices and become county coroners. Can we expect that from him?

The essay then segues from Dr. Ideal to the philosophical ideations of Karl Jaspers. Makes sense. Jaspers evidently was a very smart guy.

But as a pragmatic solution to what’s bothering psychiatry? It’s hard for me to imagine a run on Jaspers titles driven by newly energized psychiatrists anxious to now do it right because Dr. Pies pointed out Dr. Ghaemi’s elegant elucidation of Jaspers.

No, what Dr. Pies does is move the dysfunctional food of normative psychiatry around the plate. The “we need” and “we must” evasions are cheap. An empty “we need” platitude and two bucks will buy a cup of coffee. Toss in an effusive Schlozman concurrence and three additional bucks and you can buy a Danish on the side.

Let me ask Dr. Pies. (and Dr. Schlozman). What are some real, concrete, actionable solutions that they would recommend to improve the quality of psychiatric services provided to patients? What I’m waiting for from Dr. Pies are actionable recommendations for repairing defects in the normative training and practice of psychiatry. Dr. Carlat pitched his. OK you don’t like them. But they are real. So step up and offer your own beyond the platitudes.

Oh, that’s right. You won’t. Because my last name is obscured. How convenient…

Elaine Schattner, M.D. said...

I just don't see this as a prudent strategy. There's too much we need for doctors (shrinks and PCP's included) to know and understand about the body, molecular sciences and pharmacology before they're ready to interpret new findings, recognize signs of illness and prescribe treatments. All that's besides issues of maturity, practicing interpersonal skills, medical ethics, etc.

Ronald Pies MD said...

Hi, Dr. Schattner--I am glad to see that your perspective brings psychiatry firmly into the fold of general medicine,where it belongs (though I prefer the term "consciousness expanders" to "shrinks"!).

I also agree that what separates physicians from other excellent but non-medical clinicians is our immersion in molecular sciences, pharmacology, internal medicine, hematology, etc. So it is with some hesitation that I suggest that the medical school curriculum could be condensed to 3 years. I would like to see, first, a major commission report--akin to the classic Flexner report on medical education--examining the question, before I committed to a 3-year curriculum. Still, my instincts and experience tell me that careful condensation of the basic science material (e.g., histology, anatomy, physiology, biochemistry) could allow for such a shortened program.

That said, I would favor an expansion of the psychiatry residency to 5 years, in order to enhance skills in consultation-liaison psychiatry, the neurosciences and psychotherapy. This is ambitious, I know: it aims at making psychiatrists both better general physicians and more seasoned psychotherapists. But I believe psychiatry's position as a medical specialty would be strengthened by just such a program.

This is not without precedent, in that several residencies are now 5 or 6 year programs; e.g., the American Board of Psychiatry and Neurology has already approved a 6-year, combined program in Psychiatry and Neurology; and there is also a five-year, ABPN-approved program in Family Practice and Psychiatry.

Ronald Pies MD

Evan J said...

As a graduate of a former 3 year medical school (now 4 year), it seems like a good idea in theory, but in practice, not so much. As Susan said above, you lose almost all vacation and recovery time. God help you if something goes wrong, and you fall out of step with the tightly packed curriculum. Graduates are tired and burned out before starting their residencies. There is less time for electives, leaving many unsure of their choice of specialty by matching time.

The value of being a psychiatrist is that we are also trained as physicians. As such, compared to other mental health professionals, we are better prepared to understand, evaluate and manage disease processes and foresee complications and interactions. Not all of us choose to maintain and use that body of medical knowledge, and many practice in settings where it's next to impossible. Still, it's difficult for me to comprehend how a non-medically trained "psychiatrist" would substantially differ from a "psychiatric" nurse practitioner or a prescribing psychologist.