Much of medical education is careening into an ideological ditch. Following the directives of the “health equity” movement, med schools have veered off the course of teaching future doctors the basics of anatomy and various medical procedures to instead discuss how systemic racism causes back pain or how doctors can raise their own “critical consciousness.”
This innovation in medical education is not only successful in itself but points to a better approach to higher learning more generally.That being said, there are a few medical schools, such as NYU’s Grossman School of Medicine, that are heading in a new, surprisingly promising direction: They’ve crammed the traditional four-year course of study into three years, trimming the electives and carrying classes through the summer. This simple innovation in medical education is not only successful in itself but points to a better approach to higher learning more generally.
Superficially, such a change reeks of lowered standards. K-12 schools have gutted their curricula of any rigor and pass all students along, a trend that has led to a higher number of remedial courses becoming necessary at the collegiate level. Perhaps such mediocrity has finally reached medical schools, forcing them to ease up on their stereotypically unforgiving curricular demands?
Quite the contrary. A 2022 study comparing three-year medical schools to their traditional counterparts found that accelerated students entered their training with comparable admissions standards, achieved similar scores on medical examinations, and performed as well in their first year of residency. A follow-up comparative study from 2024 confirmed these results: There’s no marked difference in achievement between students who attend three- versus four-year medical schools.
There’s a famous thought experiment called “Chesterton’s Fence” that can help to frame this discussion. In it, G.K. Chesterton suggests that the purchaser of a new property should not tear down any fence until he knows the reason the fence was first erected. Do so too hurriedly, and the property owner may find snow drifts blocking his windows or wolves among the sheep.
Typically, Chesterton’s Fence justifies the maintenance of existing traditions, habits, institutions, and practices. Just because we do not know the value of this or that institution doesn’t mean it has none.
In this case, however, the fourth year of med school may very well be a fence that we can now deconstruct. We know why early med-school founders created a four-year course of study, and, as previously covered, more research is coming out that demonstrates the questionable utility of that fourth year.
Prior to the 20th century, medical education was a disorganized hodgepodge of private, for-profit institutions. There was no standardization, no quality control, and no clear definition of what a doctor ought to know or be able to do. Indeed, such was the state of all of higher education.
But, as detailed in Frederick Rudolph’s Curriculum: A History of the American Undergraduate Course of Study Since 1636, that began to change in the progressive era. With their new faith in rationalism and technocracy, college reformers fostered a widespread standardization across higher education. These reforms largely focused on inputs and processes: What were the accrediting bodies? How large must endowments be for an institution to be considered a university? How many hours should students attend classes? How many PhDs must a college have on staff? How should colleges organize their departments?
More research is coming out that demonstrates the questionable utility of med school’s fourth year.Much of this reformist zeal came through the reports and analyses of the Carnegie Foundation. And perhaps no reform was more influential than the simple Carnegie unit or credit hour, which normalized the link between the length of classes and academic achievement.
Similar reforms came for American medical education. In the early 1900s, the Carnegie Foundation commissioned a report on medical education from Abraham Flexner. Impressed by the program at Johns Hopkins, Flexner recommended a four-year course of study—the first two years focused on content and the latter two on clerkships and application—that subsequently became the accepted standard for medical education across the country. Combine Flexner’s report with the broad acceptance of the Carnegie unit (time equals learning), and the four-year medical school became sacrosanct.
But Carnegie’s approach, emphasizing inputs and formalized processes, needn’t be the only way. Standing as the polar opposite is Milton Friedman’s emphasis on outputs. What does it matter if someone masters human anatomy and pharmacology through a formal medical school or through autodidactic studies? If a student scores well on his or her medical boards, what does it matter if he or she has attended a three- or four-year medical school? That one has learned the material (the output) matters more than how one came to understand it (the input). In his famous book Capitalism and Freedom, Friedman goes so far as to recommend an entirely deregulated, de-standardized medical education.
We needn’t accept Friedman’s recommendation of total deregulation to accept that there’s room for experimentation and modification in medical education. Writing in Law and Liberty earlier this year, Scott Yenor noted that, since the progressive reforms that standardized American education from kindergarten through college and eventually professional schools are only about 100 years old, we can reconsider and rebuild them. We can tear down Chesterton’s Fence and build something better in its place. Of medical education, he writes:
Why is an undergraduate degree necessary for entry into medical school or dental school? Germans can go from gymnasium to medical school and be practicing medicine by the time they are 26 or 27. American doctors must go through K-12, then undergraduate, then medical school, and begin practicing when they are around thirty. Our system of credentialing and certification, born of the progressive reform, makes this necessary.
Elements of the old system—like entrance exams—could be reintroduced. To dismantle this system, it might be necessary to mandate that all medical schools offer a real testing admissions option, where high schoolers can take exams and win admission with a sufficiently high score. Medical school enrollees, for instance, could be required to know a lot about biology, anatomy, and organic chemistry on admissions tests.
The three-year medical school would fit well into such a system of medical education. Simply, schools may provide a basic course of study for prospective doctors looking to enter less technical specialties such as family practice, whereas more challenging specialties, such as pediatric neurosurgery, may still necessitate four or even five years of medical school.
To last, three-year programs must exist as their own model, not just as a budget variety of the standard one.To make these programs scalable, there are required policy plays. Three-year programs have waxed and waned before, and, each time, student and faculty stress, not mediocrity, has caused their decline—the difficulty of cramming four years of curriculum into three. To last, three-year programs must exist as their own model, not just as a budget variety of the standard one.
For this to occur, accreditation requirements and state licensing laws must shift to securing outputs, not inputs. For example, medical-school accreditation requirements are heavy on the process, dictating a minimum number of weeks and exposure to the entire field of medicine. But must a prospective doctor who knows he wants to specialize in obstetrics spend 24 weeks in electives, rotating through every specialty? If policies focused instead on the scores of students on their Step exams—the licensing exams of prospective physicians—regardless of the route they took to earn them, then three-year programs could develop their own processes. Perhaps a particular three-year program would focus on primary-care physicians, allowing it to streamline its curriculum and cut back the 130-week minimum, thus making an efficient pathway for obstetricians, practitioners of family medicine, and internists.
The three-year medical school is a simple innovation by itself. But, as school choice spreads at the K-12 level and more people seek actual learning rather than a bureaucratized process, such programs will ideally become a reflection of an expanded, diversified, and thereby better education system.
Daniel Buck is an assistant principal at a classical charter school, a senior visiting fellow at the Fordham Institute, and the author of What Is Wrong with Our Schools?