<p>There are some very good points in the article, and while I don’t think massive changes will reach the system any time soon, there are some points that are changing. </p>
<p>For example, the American Board of Pediatrics is looking at reducing the length of some fellowships - currently all peds fellowships are 3 years, which in some cases is a barrier to recruitment to these fields (there’s zero need for someone to spend 3 years doing adolescent medicine in order to become board certified other than that’s the way it’s always been). Peds is interesting because for a very long time, fellows were the driving force behind pediatric research, and because of the smaller numbers of patients needing subspecialty care, almost by definition, specializing meant you were going to join an academic center. But since peds specialization doesn’t lead to the big monetary gain that it does in the adult world, spending the time on all that training doesn’t make sense for a lot of people. One of my good friends loves adolescent medicine, but feels it makes more sense to join a big group general peds practice and tell all his partners that he’ll take all the teens they want to give him (and there are many, many general pediatricians who will be more than happy to take him up on that offer so they can focus on the little kids and babies) rather than spend 3 years just to add some extra certificates to his wall - he’ll get to do the same thing he wants either way.</p>
<p>There are also growing numbers of combined programs in other residency fields - another friend is in a combined general surgery residency/vascular surgery fellowship. But the progress in this area is slow.</p>
<p>While the authors are probably right that there’s unlikely to be a significant decrease in quality with shorter training, I think a major component that will make people reluctant to really push for systematic change is that there’s a very significant number of people who need the time and exposure to really determine their ultimate career path. There would have to be ways to allow people to shift between the accelerated path and the standard track once they solidified their decision (or vice versa). For the number of people who could realistically cut out that extra 4 years they talk about, there are probably orders of magnitude more who need every last second to make a decision that’s right for them. </p>
<p>As a personal example, I could have succeeded with taking a year out of undergrad (though I would never trade my undergrad experience for anything and encourage everyone to take a full 4 years), and likely done okay with a condensed pre-clinical set up (it’s not like my grades were that great anyways so was the extra time really that helpful?). As far as residency goes, I’d be one of those ones who would have benefitted from an accelerated path to fellowship, because I knew which one I wanted, but that’s only because I had exposure to it as a medical student. And it’s only because I was exposed to the PICU in August of my 4th year that I would have been prepared to apply to an accelerated track for residency. If my electives had been in a different order…it might have been March and well out of my hands to have taken advantage of the system - unless there was a way to switch back and forth.</p>
<p>Meanwhile, I have friends in residency who are still trying to decide what they want to do, what type of fellowship they want to apply for. In peds, neonatology, heme/onc, GI, ID, Endocrine, and Pulmonology are all applied for starting in January of the 2nd year (Critical Care, Emergency Med, Development, and Rheumatology are July of 3rd year), and for many people, there’s simply not enough exposure to the fields that early to decide that yes, this is my career choice. The fellowship match for Internal Medicine was just moved from Spring of 2nd year to Summer of 3rd year for this exact reason. So many people are split between two fields or in some cases more. The corrollary though is how do you let people who do figure out their decision in say September of their 2nd year benefit from the accelerated path without throwing their schedule and clinical responsibilities in to chaos? For the medicine and pediatrics programs, do we begin to accept that programs simply won’t produce a % of their residents as board certified generalists? </p>
<p>Anyways, it’s interesting, and certainly a work in progress.</p>