As the United States prepares to ramp up its medical education system in order to deliver the anticipated increase in physician numbers, lessons from and contrasts with PA education are worthy of discussion. One question arises about the efficiency of modern medical education: Does it take seven or more years to prepare physicians for generalist roles, particularly when PA education has shown that a similar task can be accomplished in far less time?

Eugene Stead's seminal notion of more than 60 years ago that gave birth to the PA profession was that physician education was too long and that medical education was distorted in its mission. Medical education, then as now, is characterized by a reductionist approach, wherein research and a singular biologic focus crowds out teaching, caring for patients and addressing broader public health issues.

A Call for Change

Cooke and colleagues recently have called for a fundamental redesign of the content of medical trainingfor example, placing greater emphasis on the social, economic and political aspects of health care delivery.¹ They note that "in academic hospitals, research quickly outstripped teaching in importance, and a 'publish or perish' culture emerged in American universities and medical schools. Research productivity became the metric by which faculty accomplishment was judged. Thus, today's subordination of teaching to research, as well as the narrow gaze of American medical education on biologic matters, represents a long-standing tradition."

True enough, but this article made little mention of some other issues related to medical educationspecifically, the possibilities and existing models that could make the process shorter, more focused on the needs of society and thus more efficient. These tenets, as we know, comprise the heart of PA educational programs.

It was of interest, then, that following the publication of this article in the New England Journal of Medicine, a letter appeared there broaching a compelling point. L. Allen Kindman, a North Carolina cardiologist, states: "Cooke et al. succinctly summarize the challenges involved in training physicians. However, they do not discuss the elephant in the room. Physician assistants have a 2-year postbachelor education program, as compared with a 7-year postbachelor program for internists, pediatricians, and family practice specialists. Physician assistants receive much of their training 'on the job,' having moved on with their lives and minimized their educational debt. In many practice settings, physician assistants and their nursing counterparts, nurse practitioners, function highly autonomously. Two years or 7 years-what can allopathic and osteopathic medical education learn from this?"²

How Long Is Too Long?

Yet few in academic medical education seem to be interested in the lessons that have been learned from PA education. While there is some discussion of reducing the length of residency training in medicine and general surgery, and one osteopathic medical school has instituted a three-year primary care track,³ there does not appear to be much discussion of the obvious realities of the outcomes of training PAs. In asking the rhetorical questiontwo years versus seven years of education-Kindman is making a cogent point, one that is obvious to those of us in PA education. PAs learn medicine and enter practice efficiently, and that is the beauty of the concept.

I recall one critic of medical education, particularly as it relates to the preparation of primary care physicians, likening the current system to putting all bus drivers through astronaut training. It is overkill for the role expected in practice. PA education has shown us that it is possible to train health care providers who are capable of most of the functions required of a generalist provider in a shorter time frame.

Harvey Estes, a colleague of Stead who shaped the profession during its first two decades, said, "The educational system producing physician assistants is more advanced, efficient and cost-effective than that producing physicians."⁴ The validation of all of this is seen in the health career choices young people are making. All of us in PA education are now familiar with the candidate who has the required grade-point average to be admitted to medical school but makes a choice to forego medical school to enter PA training. These persons have weighed the options related to the professional rewards and the length of training and have selected the PA profession.

The PA Paradigm

It is time for medical educators to consider and incorporate the lessons learned from the PA profession. Perhaps undergraduate medical education could be restructured to allow entering students to select a generalist versus specialist track, where the former would be a shorter period of training. Changing the fundamental structure of medical education, the original aim of Drs. Stead and Estes, is a formidable challenge that is much easier said than done.

Mark Twain, a fierce critic of medicine and physicians in his time, is reported to have said that it is easier to move a cemetery than to change the medical school curriculum. After more than 30 years working in medical schools, I can attest to the truth in that statement. Nonetheless, we must persist in that discussion. Perhaps the comments of physicians like Kindman, who have worked with PAs and who are familiar with their career and societal advantages, are those that must continue to carry this message forth.

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

References

1. Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006;355:1339-1344.

2. Kindman LA. Medical education after the Flexner report [letter]. N Engl J Med. 2007;356:90.

3. The Lake Erie College of Osteopathic Medicine introduces the Primary Care Scholars Pathway Fall 2007. Available at: http://www.lecom.edu/lecom/pcsp. Accessed January 31, 2007.

4. Estes EH Jr. Training doctors for the future: lessons from 25 years of physician assistant education. In: Clawson DK, Osterweis M, eds. The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Washington, DC: Association of Academic Health Centers; 1993.