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Research in medical school: The need to align incentives with value (part 3)

In my last two posts (Part 1 and Part 2), I explored the research paradigm of American medical training. The takeaway was that research requirements may create inefficiencies that have a host of consequences, including an unnecessarily long training process, a potential physician shortage, and an underutilization of talent.

In this post, I’ll lay out a vision for a training process that can produce a more effective physician workforce. The role of a physician has changed over time, and the education system must evolve to keep up. I’ll consider three topics: what students should get out of medical training, how schools and residency programs can help them do it, and how the system at large can enable schools to make changes.

What should students get out of medical training?

First and foremost, medical training should produce doctors who have a strong understanding of human health and disease and have the clinical skills to translate that understanding into patient care. The goal should be to produce good clinicians – that’s what the vast majority of doctors will focus on in their careers.

With that said, I accept the premise that medical training is not exclusively about clinical skills. Physicians are bright, capable individuals, and are uniquely positioned to improve the health status of their patients by other means. Schools should empower their students to pursue those opportunities. For the reasons I discussed in my last post, medical schools have decided that the primary way to do that is through research.

Research is one way to push extraordinarily important advances in medicine, but it isn’t the only way. Doctors can also improve their patients’ health by taking on roles in community health, policy, entrepreneurship or management, among others. These involve many of the same skills and techniques as research, but medical trainees don’t get exposed to these opportunities. We should.

How can schools fulfill this mission?

So how can the education system make this happen? At some point, whether it is in college or medical school, students should be given the flexibility to explore multiple domains of medicine and health care. They should then be able to pick the one or two that fit their interests and pursue them in more depth. Many students will choose to do research, while others will select other specialties. If students explore these opportunities and decide that they would rather focus on being an excellent clinician, that should also be doable.

This would allow physicians to become more effective leaders and decision-makers in the health care system. The traditional training process treats medicine as a universe of clinical practice and research, but the physician workforce has unfulfilled potential across a spectrum of other fields.

This seems intuitive, but the status quo hasn’t changed. Students might have a chance to explore other arenas, but markers of success revolve around research. Consider a student who is interested in a competitive specialty – let’s use neurosurgery as an example. The average student who matched into a neurosurgery residency in 2014 had approximately 12 publications (including abstracts and presentations). The number is likely higher for competitive programs within the field. Someone who wants to be a neurosurgeon will often dedicate several years to research even if they would have preferred to focus on other domains. And it’s not just neurosurgery; for instance, plastic surgery and radiation oncology residents average more than 12 publications. For reference, most PhD students, whose sole focus is research, graduate with fewer publications.

There is no particular reason a student should be expected to have 12 publications in medical school. It’s perfectly reasonable to expect these students to be smart, driven, and accomplished. But the training system needs to evaluate productive and intellectually stimulating work even if it does not end up in a journal.

How can the system at large support this change?

While medical schools and residency programs have some power to enact change for their students, they are responding to incentives as well. Institutional prestige and money are contingent on research output. Most training programs have little reason or ability to fight this system.

Real reforms to medical education most likely have to happen from the top-down. This of course begs the question: Who’s at the top? Unfortunately, there isn’t an easy answer. Determinants of prestige are some blend of general perception, historical factors, published rankings, and other factors. It’s difficult to push reform by simply trying to change perception.

The distribution of money may therefore be the best way to restructure incentives. Fortunately, it’s easier to figure out who has the money. More specifically, the government is heavily involved in funding medical schools, residencies, and research efforts. Some of that money can be redirected towards programs that try to improve health by diverse (i.e. non-research) means. There is precedent for this type of funding; for example, innovation grants for hospitals that develop new models of health care delivery. And if institutions receive funding and recognition for their work, they are more likely to encourage their students to contribute to it. The government may also allocate funding to training programs that have an entirely clinical focus.

Obviously, we should not haphazardly implement new ideas and take away resources from programs that have been successful. But the reality is that a great deal of government funding (from the National Institutes of Health, the Centers for Medicare & Medicaid Services, and other involved agencies) is not used well and creates poor incentives. That needs to change.

Conclusions

American health care has changed enormously over the past century. Old challenges have been solved while new ones have arisen. Doctors and medical students have the capacity to meet these challenges but are hamstrung by an education system that hasn’t kept pace. I recognize that medical education is difficult to design and new ideas need to be tested and refined. But once we update medical training to align incentives with value, I’m confident that the physician workforce will become an even more formidable force in combatting illness.

This piece is re-posted courtesy of the Stanford School of Medicine’s medical blog Scope, and is Part 3 of a 3-part series (Read Part 1 here and Part 2 here). Read the original piece and check out more writing on Scope here.

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