Learning and retaining medical knowledge is a greater challenge for students today than ever before. Some see this as an opportunity. Others see that business opportunity as a threat to established medical education.
In 1950, the doubling time of medical knowledge was estimated to be 50 years. By 2010 that had shrunk to 3.5 years and by 2020 it is projected to be just 73 days. With each passing year, medical students are required to learn more material than did their predecessors. Further adding to the burden is the increasing importance of standardized examinations, particularly the formidable United States Medical Licensing Exam (USMLE) Step 1. An eight-hour-long endeavor, Step 1 tests mastery of the basic sciences, also known as the preclinical curriculum. It is widely considered to be the single most important examination for placement into residency programs after medical school.
Are schools providing the tools to help medical students isolate and retain essential information, and so excel on licensing exams? If students’ study habits are any indication, the answer seems to be no. Rather, the sheer volume and complexity of tested material coupled with the high stakes of these exams has allowed third parties to flourish and capture students’ time, attention, and money.
The student-to-teacher ratio has historically served as a marker of educational quality. The internet has upended that, enabling high-quality education with a one-to-many format. Established test preparation giants such as Kaplan have bolstered their web offerings. So too have smaller niche players, including UWorld, USMLE-Rx, Pathoma, and Doctors In Training. In the past seven years, a myriad of technology-driven medical education startups has also arisen — Picmonic, Firecracker, and Osmosis, to name a few. These resources focus on improving high-yield content retention using concepts such as associative memory, retrieval practice, and spaced repetition.
Medical students, frustrated by the inconsistency of faculty-delivered curricula, are universally adopting new platforms and products not only as study aids but in many cases as substitutes for textbooks, class lectures, and notes.
Medical schools have had mixed reactions. Some institutions are recognizing the popularity of commercial products and negotiating volume discounts for their students. Others disregard or even discredit third parties, remaining firm believers that the institutional curriculum should be adequate preparation for licensing exams.
Still, with students shifting focus from institutional curricula to external resources that “teach to the test,” it’s time to view third parties as disruptors and their products as disruptive innovations. Markers for impending disruption are usually unhappy customers and extremely profitable incumbents — in this case overwhelmed medical students getting increasingly expensive educations. Yet, the high barrier to entry for potential competitors — accreditation, clinical partnerships, educational brand, and the like — has shielded traditional medical schools from having to face and respond to true competition.
In the short term, third parties can’t entirely replace training institutions. But they are rapidly exposing inadequacies in the traditional US medical education system. Students are spending heavily on commercial resources that optimize content selection and delivery. Preclinical medical education — traditionally the first 18-24 months of medical school — has effectively been outsourced to third parties. This brings to mind the likes of Netflix, which began as a mere third party, then transformed content delivery and consumer habits, and ultimately brought about the extinction of brick-and-mortar video stores.
The sustained growth of third-party companies in medical education will rely in part on the continued importance of licensing exams. If, as some thought leaders are starting to recommend, residency programs move from their reliance on test scores to a more holistic assessment of candidates, this growth may be slowed. However, developing a new, nationally comparable measure that can predict success in residency will be a time-consuming process. Convincing medical schools, training institutions, and accreditation bodies to adopt a new measure will be even more difficult.
The more that students rely on third-party materials, the more medical schools are at risk of becoming symbolic — rather than substantive — educators. Higher education is no longer just a discipline, but is also a market in which third parties are important players. Schools must recognize this and think about how proven third-party teaching methods, resources, and technology can be integrated into traditional curricula.
Whether medical schools acknowledge the competitive forces already at work and how they choose to respond will ultimately determine the nature and pace of disruption in US medical education.
Anu Atluru, MD, is a resident physician in emergency medicine at Massachusetts General Hospital and Harvard Medical School and has served as a national delegate for medical education for the Association of American Medical Colleges’ Organization of Student Representatives.