We currently have a physician shortage—and it is only going to get worse. Retirements are accelerating, patients are living longer with complex conditions and residency training slots have barely budged. If we want to ensure a robust physician workforce, we must train more doctors. And we must train them smarter, faster and more affordably—and then set them up to thrive, not burn out.
So why, nearly 15 years after we started talking about making medical school shorter, are we currently making it longer?
Delays before day one
Training to be a physician has always been a long endeavor: four years of college, four years of medical school and another three to eight years to train in residency. Recently, many students have started to take an extra year off after graduating from college to do research to improve their chances of getting into medical school.
At the other end, they may extend medical school for an extra year to get into a more competitive residency. After that, residents may spend part of their training doing research.
It’s unclear whether all of this “extra” time improves the quality of our practicing physicians, and, with National Institutes of Health funding at risk, opportunities to participate in research as a trainee or to develop a career in research are likely to be in short supply. What is clear is that the trend of taking years off or adding research years is further delaying the start of practice. As a result, almost two-thirds of medical school attendees now graduate at age 27 or older.
The high price of waiting
Every extra year in training is not only another year before doctors can practice but also another year of accumulating costs and life pressures. The longer the path, the heavier the toll—financially and personally.
New doctors face heavy loan burdens immediately after graduation, and at least three, and sometimes as many as eight, years of additional training until they start to earn at a professional fee level. Medical school graduates are handed a diploma with an average of $203,450 in medical school debt. Indeed, in 2022, the average med school graduate owed seven times as much as the average college graduate. The financial strain is now so significant that a recent study found rising rates of food insecurity among medical students—an alarming indicator of just how unsustainable the current path has become.
Making matters worse, when physicians finally reach their full earning potential, they find lower salaries: Centers for Medicare & Medicaid Services policies have reduced physician wages effectively 26% over the past 20 years. While to date, doctors have responded to these cuts by increasing productivity, the tipping point of efficiency has been met, and physicians just cannot see more patients. All of this puts enormous strain on early-career physicians. In fact, one study (PDF) found that female internists were likely to earn less over their lifetime than physician assistants were.
Unfortunately, the costs of such a long road to becoming a doctor aren’t just financial. Many physicians enter practice at the same time and age at which they are ready to start a family. This confluence of timing can particularly deter women from becoming physicians.
Faster paths and tuition relief
Patients will always need medical care. With all of the challenges facing physicians, is it possible to help the supply of doctors keep up with the constant demand for their care?
The answer is yes—but the solutions will be challenging. At the beginning of a doctor’s career, we need to find a way to streamline training without compromising rigor. Some medical schools have programs with three years of training and can provide meaningful lessons about what is working and what is not.
The key is to focus on quality rather than quantity and to identify which parts of a physician’s training are the most essential to produce the best possible doctors. That means reassessing where time is spent—on coursework, rotations and requirements—and determining which pieces are truly necessary and which could be streamlined without sacrificing competence.
We should also make tuition less burdensome, or, ideally, make medical school debt-free. This would have multiple benefits—not the least of which would be encouraging a broader and potentially more diverse group of people to become doctors. Developing shorter training tracks, with less pressure to take extra years to build up a resume, would also make the long pathway more manageable.
Tailoring medical student education to allow people to pursue their specialty interests more efficiently could also help. Some have suggested an inverse path: putting off medical school during the formative years of the twenties to accomplish other things, then beginning medical school at an older age. And, regardless of whether training time is shortened, physicians should be fairly compensated during their training. Indeed, residents are increasingly unionizing to make their case for this clear.
It’s also essential to better prepare doctors for the demands of their career. Some data show that medical students, who start with generally healthy habits, lose that balance when they start their training. Whether through mentoring, a curriculum during medical school or other avenues, it’s imperative that we train future doctors not just in their specialty, but how to practice that specialty with an awareness of its inherent challenges—and how to face and manage those challenges.
Streamlining training is only part of the solution. Once physicians complete their education, they need a system that values and sustains them. We can’t afford to ignore the physician pipeline any longer. The future of healthcare depends on how we invest in the doctors of tomorrow—starting today.
Alexa B. Kimball, M.D., is president and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center.