What Did I Just Pay For?

One year down and the greater part of a decade to go. As a first year medical student, having finished class for a couple months has allowed for ample time to digest much of what happened to me over the last twelve months, I can’t help but ask the question: what did I just sign up to pay for?

Students aren’t afforded the time to process the new information, surroundings, and lifestyle that comes with being a med student—it just sort of happens to you whether you like it or not. Medical school confronts students with a unique problem from the very first day of class: too many teaching resources to learn from and not enough time to use them all. It is up to the student to determine the most efficient way to retain information and stick with it for the year. The problem is that different subjects require different types of learning—some rote memorization, others require more critical thinking and problem solving—so there isn’t a magic bullet for getting by. Most students would agree that the material offered in medical school is not particularly difficult, there is just a lot of it. A policy at my school, along with many other medical schools, is to record all lectures and to ease restraints on mandatory attendance. This decision has deep ramifications that may end up changing the face of not only medical school, but higher education in its entirety.

The motivation behind recording all lectures with the professor’s corresponding notes is presumably to make life easier on the students, and in doing so, move medical education into the 21^st century. The theory is that if all students have the ability to go back and listen to old lectures surely test scores will rise, as will the scores for the all-important and ever-looming United States Medical License Exam (USMLE) Step 1, which is a national standardized test given to all medical students following completion of their second year.

I’m not complaining. Streamlining content and making it accessible from anywhere on the planet is certainly more beneficial to students than having to attend each lecture and furiously scribble notes while simultaneously attempting to comprehend what is being dictated. I have it easier than classes before me and classes after me will have it easier than me. This is a good thing.

Not all courses involve professors standing in a lecture hall speaking to students. There are several courses in which students are taught how to interact with patients, colleagues, and peers, as well as using small groups and teams to discuss and work through cases. These require the students to be present because some things—like interviewing patients and teamwork—just don’t translate to the digital world yet. While watching lectures at a time and place of my choosing I can pause, rewind, and increase the lecture speed to ensure that everything I need to spend more time on I can go over slowly, and material that I know well I can just skim through.

Every now and then a lecturer will get called into an emergency and cannot attend class, so the lecture from last year on the same topic will be posted online. This is also good. No classes are ever really canceled or postponed due to unforeseen circumstances because there is always the previous year’s lecture ready to be posted at a moment’s notice. Lectures that were canceled but would have discussed updated material to reflect new findings in the field would have an emailed addendum with the additional slides or lecture notes to reflect such changes.

During this year alone our class had over 20 lectures used from last year (out of over 450), most of which came during the unusually snowy winter. I appreciate the option to learn medicine while in my pajamas and not having to go to campus each day, but what if every class simply used the previous year’s recorded lectures and then addenda were sent out addressing the newest research or pertinent clinical findings so that students are current on the given topic? Since the vast majority of students don’t attend lectures anyway this would only affect 2 groups: the professors themselves and the students who do attend lectures in person. I am usually hesitant to call for automation at the expense of other people’s labor, salaries and livelihoods, but if it can be shown that the cost of paying the salaries for lecturers can be used on other important learning tools then I believe it is an interesting proposition. The average medical school tuition is over $40,000 per year with an average class size of 135 students, meaning about 8 full-time professors/faculty making $85,000 a year would need to be laid off in order to reduce tuition just $5,000/year per student. Keep in mind the cost of medical school is far greater than just tuition, and more accurately comes to $60,000 and upwards each year (with many students coming out owing well over $200,000) and does not even include interest. All of this to say that saving $5,000 or so on tuition each year is really only a drop in the bucket from a student’s perspective and money should be spent on technology and facilities that find innovative ways improve learning. Additionally, most of the professors do not teach full time but perform research on campus and use teaching as supplemental income (or it’s part of their contract), or hold other positions on the medical school staff such as advisors, committee members, etc. I’m sure many of the professors would prefer to spend more time in their laboratory and less time in front of students teaching, but would they really wish to do so at the expense of a decreased salary?

However, the real question is: if the vast majority of lectures are posted online, how far away is medical school from becoming an online degree? Facilities such as the simulation laboratory (a robot patient that interacts with student doctors and responds to treatments given), and micro and gross anatomy laboratories have difficulty translating into the virtual world, but with new technology we are not far from having a fully interactive human body that looks and responds to our scalpels in the same way that our actual cadavers do. As technology streamlines education, how will this affect students’ abilities to learn the required material? Most schools have the same core curriculum that covers standard topics that are required for the USMLE. Doesn’t it make sense to have a centralized database in which there are only a handful of professors lecturing on topics to every med student in the U.S.? This somewhat exists already for students studying for the USMLE exams. The vast majority of students use only a handful of resources to prepare for the test. Couldn’t this be adopted for actual school material throughout the year rather than only for USMLE prep?

Curriculum for U.S. med schools is not completely uniform, however, as a school in a rural area will be more likely to have classes that are geared towards illnesses afflicting the surrounding population than a school in an urban environment. This variation can also be accounted for in recorded lectures and shouldn’t deter the schools from adopting more online-only content.

The reasons for having a physical campus for medical school is to be able to put in face time with peers to create a sense of community and attend the occasional classes in which groups of students are required debate and discuss case studies. Extracurricular activities and student groups also need places to meet. Students should meet with their advisors and professors for office hours, although I will admit that the increasing ease and frequency of video conferencing programs such Skype makes this less pressing. Students need to be face to face with their “mock patients” when conducting interviews and physical exams, but even the traditional doctor-patient relationship is becoming a thing of the past. As of this point, learning the hands-on aspects of becoming a physician cannot be substituted for an internet connection. In the same vein, gross anatomy needs to be attended by students because getting close to the cadavers is an important experience that means more than just learning to cut flesh and identify organs. It is important to strip away much of the excessive or redundant amount of information coming at the student, yet keep the humanistic and emotional aspect of learning to become a more complete physician intact.

The physical med school will require adequate study space, but a library with books is certainly not as necessary as it once was. As a matter of fact, I recently received an email from my school notifying all students that librarian hours will be cut to 20 hours per week due to the lack of student demand. Of course the library will remain open 24/7 but faculty and staff will no longer be available for as many hours. With almost all textbooks having digital formats, less and less space will be needed on bookshelves but students should have the opportunity to order physical books through their library, or a central library in a city or region. I began college in 2004 and all textbooks in biology were over 500 pages, weighed 10 lbs. and cost hundreds of dollars with a new addition of the book arriving every other year, making the books resale value almost nil. My younger brother recently graduated from college studying biology and all of his textbooks were digital, much cheaper, contained animations of biological pathways and reactions, and have the added benefit of being able to download updates so that the book always has the newest material. This is how the new generation of doctors will be studying. I still like the feel of paper between my fingers but there’s no reason to prefer it beyond familiarity and nostalgia. Digital formats are superior in every aspect except maybe they’re a little harsher on the eyes (but that could also be because I didn’t grow up staring at monitors).

The med school of the future still needs to contain conference rooms and an auditorium for notable lecturers or guest speakers so that more ears can be reached rather than speaking to a mostly empty room but with a digital camera pointed at the speaker. Something needs to be said about being in the presence of a great speaker who can advocate passionately about their novel ideas, and the sound of clapping that gives energy to a room can really make their notions hit home.

Ultimately if students are doing 80% of their learning in front of their computer screen is there a point where administrators have to be careful so that students don’t start to ask, “am I getting my money’s worth?”

If more schools develop online-only learning tools, how will teachers and professors be viewed by society? Will they be marginalized in their own classroom and become relegated to only answering the sparse questions from the student that can’t find his answer on Google? Will this shift free up more time for professors at higher institutions to pursue their own research or projects regardless of the field? These are the questions that medical schools will begin to face as more universities begin to shift their content into online databases that can be accessed by enrolled students as well as the public.

As tuition skyrockets and students are saddled with hundreds of thousands of dollars of debt, many feel as though they need to make up for lost time not spent earning a paycheck in the workforce and become highly specialized physicians. Highly specialized physicians are great when there is a pressing need for them, but the Association of American Medical Colleges (AAMC) reports that there will be a shortfall of 45,000 primary care physicians by 2020 so more needs to be done to incentivize students to pursue more broad (and often lower paying) types of doctors. There is also projected to be a shortfall of specialty physicians, but if primary care is emphasized in America, the use of specialty physician will wane as diseases and other illnesses will be caught and treated earlier rather than being able to progress to more difficult-to-treat stages which ends up increasing health insurance premiums across the board.

Another effort to lower costs of medical school is being explored by New York University, and having a 3 year medical degree. Although this is a new frontier for U.S. schools, where is the incentive for a private university to completely forego millions of dollars from its students by axing a year of payable tuition? This is another example where the profit-motive and efficient and effective healthcare do not coincide. The medical school industry, much like healthcare in the U.S., needs to reduce costs but maintain its efficiency in pumping out quality physicians. There is a difference between taking shortcuts and cutting corners and right now medical schools in the U.S. aren’t doing either, which is hurting both medical students as well as the future delivery of healthcare in America. The shortsightedness of the medical education system is forcing students to rack up enormous amounts of debt which ultimately will end up harming the population decades down the line either because the debt will discourage enrollment, or students will feel compelled to pursue higher-paying specialties rather than serving in a more utilitarian role. Medical schools would be wise to implement cost-saving measures that may prove to enhance student training while by embracing the latest technological advances. In many circumstances bloated industries and less-effective methods would be phased out by new and cheaper start-ups. In the highly regulated medical school field this type of progress is impeded by old ways of thinking and layers upon layers of bureaucracy. The last thing anybody wants to think walking out of the supermarket, a car dealership, or a campus is, “What did I just pay for?”