Rebuttal to “Why I don’t want to go to med school”

My friend just started a blog. This is one of its inaugural posts: Why I don’t want to go to med school.

I respect the majority of this article. I agree with most of it — the North American medical education system is clunky, and a ton of hurdles are thrown in the way of students who want to become doctors.

Underlying differences

I think, however, that there is a premise not shared between the rest of the world and North America: the idea that it should be “easy” to become a doctor (or, for that matter, any other profession, like a lawyer).

A document called “Medical Education in the United States and Canada” from 1910, subtitled “A Report to the Carnegie Foundation for the Advancement of Teaching” opens with an introduction that contains these words:

… the history of medical education in this country and its present status are set forth. The story is there told of the gradual development of the commercial medical school, distinctly an American product, of the modern movement for the transfer of medical education to university surroundings, and of the effort to procure stricter scrutiny of those seeking to enter the profession.

Back when the system was evolving, there was an issue of “enormous over-production of uneducated and ill trained medical practitioners”. To address it,

progress for the future would seem to require a very much smaller number of medical schools, better equipped and better conducted than our schools now as a rule are; and the needs of the public would equally require that we have fewer physicians graduated each year, but that these should be better educated and better trained. … Society forbids a company of physicians to pour out upon the community a horde of ill trained physicians.

In essence, the modern North American medical education system evolved from a much earlier time when it was necessary to reverse the trend of unqualified physicians. And though we no longer face the issue of “ill trained medical practitioners” to the same degree, the same mentality that this should be a difficult profession to enter has stuck.

And, well, it’s much harder to change this established consensus than it is to reform education.

Deciding to enter medicine

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See, if it were meant to be an easy road, everyone who wants social respect and good salaries would already be a doctor, or lawyer, or whatever else is hard to become. (But perhaps the social respect and good salaries would vanish quickly.)

Premeds here don’t just decide fleetingly that they want to become doctors. It’s not as simple as flipping a coin. It’s supposed to be a decision with consequences, and one that requires an investment — an investment of time, money, and soul. And that’s why, even while we bemoan the high GPAs we need to maintain, and the debt we foresee, we persist rather than complaining that we wish we were in a system that made it easier.

1982 study of medical students in Australia found “that the students tended to endorse social/altruistic reasons (working with people, helping others) and the opportunity to become involved in a challenging occupation as the most important reasons for their occupational choice. Other reasons, such as satisfying one’s parents or having the opportunity to achieve high social status and to benefit financially, were rated much lower in importance.”

Another one of my high school friends said to me last summer: “Dude, you don’t become a doctor to get rich. That’s what business is for.”

Heck, even this well-known rant about why you should not go to medical school acknowledges:

And the one reason why you should go into medicine:

You have only ever envisioned yourself as a doctor and can only derive professional fulfillment in life by taking care of sick people.

There’s really no other reason, and lord knows the world needs docs. Prestige, money, job security, making mom happy, proving something, can’t think of anything else to do, better than being a lawyer, etc are all incredibly bad reasons for becoming a doc.

You should become a doc because you always wanted to work for Médecins Sans Frontières and your life will be half-lived without that. You should become a doc because you want to be the psychiatrist who makes a breakthrough in schizophrenia treatment. You should become a doc because you love making sick kids feel better and being the one to reassure the parents that it’ll all be OK, and nothing else in the world measures up to that.

(The author graduated from medical school, and that rant is actually a good read. Not that this is meant to be an attack on his character, but he went on to write dating books. More lucrative than being a physician, maybe?)

I think the medical education / physician training system here in North America forces students to be more certain about their choice to enter medicine. And one might just argue that it’s a good thing the system deters my friend from going to med school. Forget whether the 4-year undergraduate is valuable educationally — I care more about whether the doctor that comes out of the entire process is as dedicated to doing his job well, after finally earning his right to practice.

It’s a rite of passage.

The important thing, and a most intriguing phenomena, is that the fact is, that once entered upon, a medical education is so very seldom abandoned for anything else. In short, it is the rarest of phenomena to encounter an ex-physician.
– Dr. Walsh McDermott, speech from the Cornell archives, quoted in “On Entering Medicine” by David E. Rogers, MD

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The last paragraph of Kirill’s post says:

Judging by quality-of-life indicators and worldwide assessments of healthcare standards, it doesn’t seem like this North American approach to medical education is producing better doctors. Not only do we get screwed when it comes to the costs of education, but we have to spend twice as long in school to get the same degree. All for what? Better doctors? Doesn’t seem like it. Higher salaries? Maybe by the time you’re 50. Does it somehow lead to an efficient and accessible health care system? Most certainly not.

I don’t think this last paragraph is defensible.

One cannot make an unqualified statement that the medical education system is not producing better doctors unless one corrects for all of the other factors affecting those indicators. Quality-of-life indicators and health care standards are affected by external factors. They consider a wealth of input variables, like political climate, or the fact that North Americans experience high rates of lifestyle-preventable diseases that have nothing to do with physician education

This conclusion at the end of an otherwise well-written comparison of worldwide physician training systems is the equivalent of comparing farming apples and oranges in different climates and concluding that not one technique makes better fruit. The farming technique must suit the fruit and the climate, and the climate contributes just as much as — if not more than the technique — to the growth of the fruit.

Unless one corrects for the environmental factors (e.g. more Americans don’t currently have access to health care for economic reasons aside from physician education, in comparison to the other countries used to compare physician training), one cannot claim that the North American approach doesn’t produce better doctors.

(I’m not saying it does — I’m just pointing out that there’s not enough basis to make the claim it doesn’t.)

For the closing two lines: it might be true that the United states doesn’t have a more efficient and accessible health care system. But is this accessibility for the physician or for the patient? If it’s about accessibility for the doctors, I’ve already addressed that the underlying philosophy here isn’t meant to make it easily accessible. If it’s about accessibility for the patients, there are far bigger societal hurdles to tackle than the time and cost investment for doctors.

I don’t really have a view on how North American medical education should be

I think what we have in North America is a flawed system that deals with concerns far beyond the scope of an individual medical student. It maintains the elitism of the profession, (intentionally) increases the barriers to entry, and protects the jobs of those currently in the industry.

These aren’t things students care about — “I just want to break into this field and start my career” — but they might be relevant once students earn their right to practice. And, in a twisted way, since doctors here have all had to face their rite of passage, there is an inevitable resistance to any sort of systemic change. The same goes for lawyers, and other professions.

But in the end, I don’t have a clear idea of how it should be. I can’t imagine trying to convert the American/Canadian medical education system to what the rest of the world has — there’s simply no way to do that other than forcing all the medical schools to accept students right out of high school. Can you imagine what the backlash from current doctors and current premed/medical students would be? It would simply be impractical.

I admit there are strengths to a shorter period of training, but this post is my requisite defence of North American medical education and physician training — and a not-so-subtle reminder that, here, one needs a far better motivation to become a doctor than making money.

3 Replies to “Rebuttal to “Why I don’t want to go to med school””

  1. Okay, I’m going to say the same thing I told you in a Google-chat earlier: you’re “rebutting” a point that I never made. At no point in anything I wrote did I say that getting a medical degree is “too difficult”, or that “I think it should be easier.

    No, certainly not. I agree with you that selection criteria should be as strict as possible — more so than for any other career. It’s a position that really *should* have barriers to entry, specifically ones that test a candidate’s knowledge and commitment to the career. GPA requirements and difficult testing are not only necessary, but could even be made more stringent than they are now.

    My point was that the medical education simply *takes too long*, and the cost factor only helps in discouraging some of the lower-income students who don’t want to take hundred-thousand-dollar loans. In the countries where a medical education takes less time, admission to the program is by no means /easier/ than it is in the US. And no one implied that the 5-year medical education itself is any easier than the 8+-year education in the States; indeed, it’s likely harder because students are learning more in a shorter amount of time.

    I’m all for selectivity and high standards for medical education, both of which can be enforced by standardized examinations or other means. I just don’t think we should be spending four years learning irrelevant material which will not help us become better doctors.

    Regarding the only part of your post that actually refutes something I said… yes, I agree, “quality of life indicators” may be a bit too broad to gauge *specific* differences in the competence and performance of physicians. However! I think it is reasonable to make an argument that IF 5-year med schools produced doctors who are (*with statistical significance*) WORSE than 8-year programs, we would see very wide divisions in international healthcare ratings! Yes, there are many factors that must be controlled for, such as the societal and governmental structure of access to medicine — but in the end, accessibility is meaningless if the person doing surgery on you doesn’t know how to hold a scalpel! So yes, it is perfectly valid of you to call me out for not citing any data, but I will still argue that if a fundamentally different education system produced better doctors, then that would be reflected with certainty in international statistical surveys.

    Also, you said the following: “Forget whether the 4-year undergraduate is valuable educationally — I care more about whether the doctor that comes out of the entire process is as dedicated to doing his job well, after finally earning his right to practice.”

    You are making as unbased a claim as I did: that the longer education period is supposedly going to make the student more dedicated to his job. You simply have no way to prove that, and to make the leap from “more dedicated” to “a better doctor” is simply unfeasible.

    You can feel free to disagree with me on this, but I maintain that “patient satisfaction” and “quality of healthcare” stats are a valid generalization to compare quality of doctors. And since these are very much comparable in most civilized countries, I will assume for the sake of this post that this means doctors are also of comparable skill. Certainly there is variation, but all laws on human rationality would suggest that if there were one country with the BEST doctors, that knowledge would be diffused worldwide, and people would flock there to get their treatments. This doesn’t happen.

    So, in the absence of a pronounced difference in skill levels of physicians (and, really, it would be interesting if you could find a study that objectively compares skill/performance with respect to years of education and country of education), we have no choice but to deduce that there is no clear benefit to a longer education.

    As an extension to that last point, I would propose the following: a longer (8-year) education should *only* be necessary if it can be found to produce better doctors. I am looking at this not only from the point of view of the medical student, but also taking into account the benefit to society. A student who spends three extra years in school is a) able to work for less years of his life, and thus spends less time helping society, and b) in the case of public schools, using more taxpayer money to finance his ridiculously high tuition. There’s an economic argument to be made here — if the marginal benefit to society from an extra 3-4 years in school is close to zero, then what the hell are we all doing?!

    (P.S. I would have loved to Google for a bunch of studies and statistics, but my power is out and there is no internet while I am writing this!!!!! — and now that it is back, 3 hours later, I don’t want to go back to write more)

    1. I chose some words carefully. Rebuttal: to oppose with contrary argument. Refutation: to show your argument itself is wrong. Most of what I’m doing is perfectly acceptable, even if you never brought up those perspectives. It’s as though I am responding to the hypothetical interlocutor.

      I’ll respond to the other points in more detail at a later time.

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