A Medical school in the United States is a four-year graduate institution with the purpose of educating physicians in the field of medicine. Such schools provide a major part of the medical education in the United States. Graduates receive either a Doctor of Medicine (M.D.) or a Doctor of Osteopathic Medicine (D.O.) degree.
Admissions to medical school in the United States is generally considered competitive. Admissions criteria include grade point averages, Medical College Admission Test scores, letters of recommendation, and interviews. Most students have at least a bachelor's degree, usually in a biologic science, and some students have advanced degrees, such as a master's degree. Most students that apply to medical school do not matriculate at a medical school. Medical School in the United States does not require a degree in biological sciences. People with degrees in different fields can be admitted to medical school as long as the criteria for admission is followed.
Medical school typically consists of four years of training, although a few programs (at least two) offer three-year tracks. The first two years consist of basic science courses, such as anatomy, biochemistry, histology, microbiology, pharmacology, physiology, cardiology, pulmonology, gastroenterology, endocrinology, psychiatry, neurology, etc. The third and fourth years consist of clinical rotations, sometimes called clerkships, where students attend hospitals and clinics. These rotations are usually at teaching hospitals but are sometimes at community hospitals or with private physicians. The typical "core" (i.e. mandatory) rotations taken in third year are Obstetrics and Gynecology, Pediatrics, Psychiatry, Family Medicine, Internal Medicine, and Surgery. Fourth year for the most part will consist of electives and some mandatory rotations like Emergency Medicine and Neurology - but again, some schools are different and some have been able to allow students to take an elective or two during third year, while many schools have also been trying to do the same. Some schools have been trying to incorporate Neurology and/or Emergency Medicine into third year, since by the time students are applying for residency programs, many haven't been exposed to either. However, again, it varies by school, and it varies by the mission of each medical school.
The Flexner Report, published in 1910, had a significant impact on reforming medical education in the United States. The report led to the implementation of more structured standards and regulations in medical education. Currently, all medical schools in the United States must be accredited by a certain body, depending on whether it is a D.O. granting medical school or an M.D. granting medical school. The Liaison Committee on Medical Education (LCME) is an accrediting body for educational programs at schools of medicine in the United States and Canada. The LCME accredits only the schools that grant a Doctor of Medicine (M.D.) degree; osteopathic medical schools that grant the Doctor of Osteopathic Medicine (D.O.) degree are accredited by the Commission on Osteopathic College Accreditation of the American Osteopathic Association. The LCME is sponsored by the Association of American Medical Colleges and the American Medical Association.
History
In 1910, the Flexner Report reported on the state of medical education in the United States and Canada. Written by Abraham Flexner and published in 1910 under the aegis of The Carnegie Foundation for the Advancement of Teaching, the report set standards and reformed American medical education.
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Admissions
In general, admission into a US medical school is considered highly competitive and typically requires completion of a four-year Bachelor's degree or at least 90 credit hours from an accredited college or university. Many applicants obtain further education before medical school in the form of Master's degrees or other non science-related degrees. Admissions criteria may include overall performance in the undergraduate years and performance in a group of courses specifically required by U.S. medical schools (pre-health sciences), the score on the Medical College Admission Test (MCAT), application essays, letters of recommendation (most schools require either one letter from the undergraduate institution's premedical advising committee or a combination of letters from at least one science faculty and one non-science faculty), and interviews.
Beyond objective admissions criteria, many programs look for candidates who have had unique experiences in community service, volunteer work, international studies, research, or other advanced degrees. The application essay is the primary opportunity for the candidate to describe his/her reasons for entering a medical career. The essay requirements are usually open-ended to allow creativity and flexibility for the candidate to draw upon his/her personal experiences/challenges to make him/her stand out amongst other applicants. If granted, an interview serves as an additional way to express these subjective strengths that a candidate may possess.
Since 2005, the Association of Medical Colleges has recommended that all medical schools conduct background checks on applicants in order to prevent individuals with convictions for serious crimes from being matriculated.
Most commonly, the bachelor's degree is in one of the biological sciences, but not always; in 2005, nearly 40% of medical school matriculates had received bachelor's degrees in fields other than biology or specialized health sciences. All medical school applicants must, however, complete year-length undergraduate courses with labs in biology, general chemistry, organic chemistry, and physics; some medical schools have additional requirements such as biochemistry, calculus, genetics, psychology and English. Many of these courses have prerequisites, so there are other "hidden" course requirements (basic science courses) that are often taken first.
A student with a bachelor's degree who has not taken the pre-medical coursework may complete a postbaccalaureate (postbacc) program. Such programs allow rapid fulfillment of prerequisite course work as well as grade point average improvement. Some postbacc programs are specifically linked to individual medical schools to allow matriculation without a gap year, while most require 1-2 years to complete.
Several universities across the U.S. admit college students to their medical schools during college; students attend a single six-year to eight-year integrated program consisting of two to four years of an undergraduate curriculum and four years of medical school curriculum, culminating in both a bachelor's and M.D. degree or a bachelor's and D.O. degree. Some of these programs admit high school students to college and medical school.
While not necessary for admission, several private organizations have capitalized on this complex and involved process by offering services ranging from single-component preparation (MCAT, essay, etc.) to entire application review/consultation.
In 2014, the average MCAT and GPA for students entering U.S.-based M.D. programs were 31.4 and 3.69, respectively, and 27.21 and 3.53 for D.O. matriculants, although the gap has been getting smaller every year.
In 2012, 45,266 people applied to medical schools in the United States through the American Medical College Application Service. Of these 45,266 students, 19,517 of them matriculated into a medical school for a success rate of 43 percent. However, this figure does not account for the attrition rate of pre-med students in various stages of the pre-application process (those who ultimately do not decide to apply due to weeding out by low GPA, low MCAT, lack of clinical and research experience, and numerous other factors).
Curriculum
Once admitted to medical school, it generally takes four years to complete a Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) degree program. However, at least two schools, Texas Tech University and the Lake Erie College of Osteopathic Medicine are now offering a three-year accelerated program for those students going into primary care. The course of study is divided into two roughly equal components: pre-clinical and clinical.
Pre-clinical study comprises the first one to two years and consists of classroom and laboratory instruction in core subjects such as anatomy, biochemistry, physiology, pharmacology, histology, embryology, microbiology, pathology, pathophysiology, and neurosciences. Once students successfully complete pre-clinical training, they generally take Step 1 of the medical licensing boards, the USMLE or the COMLEX.
The clinical component usually occupies the final two to three years of medical school and takes place almost exclusively on the wards of a teaching hospital or, occasionally, with community-based physicians. The students observe and take part in the care of patients under the supervision of resident and attending physicians. Rotations (also known as clerkships) are required in internal medicine, surgery, pediatrics, family medicine, obstetrics/gynecology, neurology, and psychiatry. Beyond these, a variable number of specialty electives are required. Additionally, students are generally required to take a sub-internship rotation where they will perform duties at the intern level. During the fourth year, most medical students take Step 2 of the medical licensing boards (USMLE Clinical Knowledge & Clinical Skills [for M.D.] or COMLEX Cognitive Evaluation & Performance Evaluation [for D.O.]).
Many medical schools also offer joint degree programs in which some medical students may simultaneously enroll in master's or doctoral-level programs in related fields such as a Masters in Business Administration, Masters in Healthcare Administration, Masters in Public Health, JD, Master of Arts in Law and Diplomacy, and Masters in Health Communication. Some schools, such as the Wayne State University School of Medicine and the Medical College of South Carolina, both offer an integrated basic radiology curriculum during their respective MD programs led by investigators of the Advanced Diagnostic Ultrasound in Microgravity study.
Upon completion of medical school, the student gains the title of doctor and the degree of M.D. or D.O. but cannot practice independently until completing at least an internship and also Step 3 of the USMLE (for M.D.) or COMLEX (for D.O.). Doctors of Medicine and Doctors of Osteopathic Medicine have an equal scope of practice in the United States, with some osteopathic physicians supplementing their practice with principles of osteopathic medicine.
Grading
Medical schools use a variety of different grading methods. Even within one school, the grading of the basic sciences and clinical clerkships may vary. Most medical schools use the pass/fail schema, rather than letter grades; however the range of grading intervals varies. The following are examples of grades used with different intervals:
- 2 Intervals = Pass/Fail
- 3 Intervals = Honors/Pass/Fail
- 4 Intervals = Honors/High Pass/Pass/Fail (or ABCF)
- 5 Intervals = Honors/High Pass/Pass/Low Pass/Fail (or ABCDF)
In addition, a Medical School Performance Evaluation, also called Dean's letter, more specifically describes the performance of a student during medical school.
Accreditation
All medical schools within the United States must be accredited by one of two organizations. The Liaison Committee on Medical Education (LCME), jointly administered by the Association of American Medical Colleges and the American Medical Association, accredits M.D. schools, while the Commission on Osteopathic College Accreditation of the American Osteopathic Association accredits osteopathic (D.O.) schools. There are presently 141 M.D. programs and 30 D.O. programs in the United States.
Accreditation is required for a school's students to receive federal loans. Additionally, schools must be accredited to receive federal funding for medical education. The M.D. and D.O. are the only medical degrees offered in the United States which are listed in the WHO/IMED list of medical schools.
Indebtedness of medical graduates
Unlike many other countries, U.S. medical students finance their education with personal debt. In 1992, the average debt of a medical doctor after residency, for those graduating with debt, was $25,000. For the Class of 2009, the average debt of a medical student is $157,990, with 25.1% of students having debt in excess of $200,000 (prior to residency). For the past decade, tuition prices have increased 5-6% each year- it is not clear what has caused these increases.
Medical schools do not have accounting transparency, so it is difficult to pin-point the root cause of tuition increases. Medical education is still based on the 2 + 2 model posited by the 100-year-old Flexner report.
A current economic theory suggests that increasing borrowing limits have been the cause of the increased tuition. As medical students are allowed to borrow more, medical schools raise tuition prices to maximally increase revenue. Studies show that schools raise prices 97 cents for each one dollar increase in borrowing capacity.
There is no consensus on whether the level of debt carried by medical students has a strong effect on their choice of medical specialty. Dr. Herbert Pardes and others have suggested that medical school debt has been a direct cause of the US primary care shortage. Some research suggests that for a sub-set of debt sensitive medical students, this is certainly the case. For most students, debt is but one consideration in choosing a residency. Whatever the cause may be, the 2008 Family Medicine Residency match filled only 44% of available slots with US graduates, down from the 1984 level of 98%.
In February 2010, The Wall Street Journal published a story of Dr Michelle Bisutti's $555,000 medical school debt. The huge amount of debt is a direct result of Bisutti deferring her student debt payment during her residency.
Indebtedness relief for medical graduates
Income-based repayment (IBR) and Pay as You Earn (PAYE) give options to lower monthly repayment based on adjusted gross income (AGI) for all Federal student loans. Physicians in public service are also eligible for student loan forgiveness after ten years of loan payment while in a public service job.
Repayment options that lower monthly payments and student loan forgiveness (PSLF) in public service are advised to medical residents slated to earn much higher salaries after residency.
Academic health centers
Medical schools reside inside complex multi-purpose institutions known as academic health centers. Academic health centers aim to educate medical students and residents, provide top quality patient care, and perform cutting-edge research. Since medical students are educated inside academic health centers, it is impossible to separate the finances from other operations inside the center. Funding for medical students--and higher graduate medical education--comes from several sources above and beyond personal debt financing.
- DGME (Direct Graduate Medical Education- 2.2 billion in 2002) financing payments under the auspices of Medicare/Medicaid. This funding was altered by the Consolidated Omnibus Budget Reconciliation Act of 1986. Each hospital receives payment based on how many Full Time Equivalent Residents are being trained.
- IME (Indirect Medical Education - 6.2 billion in 2002) adjustment. This payment compensates teaching hospitals for their higher Medicare inpatient hospital operating costs due to a number of factors.
- Managed care and insurance organizations reimburse at a higher rate for teaching hospitals, explicitly acknowledging the higher costs of the academic health center.
- The vast majority of revenues come from third-party payers reimbursing for patient care, usually through the Faculty Service Plan.
- Incentive programs such as the MSTP (Medical Scientist Training Program), NHSC (National Health Service Corps), Armed Services Health Profession Scholarship and now the Income Based Repayment Plan.
- Many academic health centers in the U.S. are tied to undergraduate university systems while others solely focus on graduate medicine, training, research, and education.
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