Physicians or medical doctors who are in charge of our health and well-being world wide, are the products of different medical training standards around the world. The medical schools training could last from 5 to 8 years to graduate a general practitioner or GP. Many medical schools around the world accept the high school graduates after an entry exam into the medical schools that mostly last about 6 years. This could be true in many developed countries such as in Europe. But in US, Canada and UK that hold higher standards in medical training, the entry into medical school is much more sophisticated, longer and more competitive. The applicants in these countries, mostly need a bachelor degree principally in biological science or alike, passing a medical entry test, MCAT (Medical Colleges Admission Test), voluntary works, references, etc. to be accepted to medical schools that is highly competitive. In these countries, then the medical schools training is four years, all focused on medical sciences, from the basic to the clinical and specialties, concluding general practitioners. But there are no jobs or positions for GPs per se in these countries without any specialties, and the shortest training for these would be family practice that lasts two years that is equivalent of GPs in other countries, only after 6 years of post-graduate studies past high school. Therefore one could easily appreciate the difference in the quality of medical training across the globe that could be translated to the quality of medical care. (1-3)
In many places in the world after graduation from medical schools, there might not be any final general exams of all the pre-clinical and clinical subjects for licensing to practice general medicine. But in US, Canada and UK there are several step exams during the medical school years and after graduation for licensing to practice medicine. In US there are three step of such exams, step 1, testing basic medical sciences in one-day of 8-hours session, step 2 consisted of two sub-steps of clinical knowledge (one-day of 9-hour test) and clinical skills (one-day of practical clinical skills assessment with mock patients). The final step licensing exam, or step 3 of USMLE (United States Medical Licensing Examination) assesses the capability of the application of basic medical and clinical sciences in a two-day exams, 7-hours the first day and 9-hours the second day including clinical skills assessment of 13 simulation cases across major medical disciplines. (4-5)
In Canada there is a similar licensing exams or MCCQE (Medical Council of Canada Qualifying Examination). The first part of MCCQE in 3.5 hours assesses the general medical knowledge, followed by 4-hours of clinical decision making scenarios assessment. The part 2 of MCCQE consists of an objective structured clinical examination in total simulated clinical sessions with patients, that could be taken after one year past the clinical training graduation.
In England, unlike US and Canada but like many other parts of the world, entry into medical schools are right after graduation from high schools, though the competition is quite high and the rate of acceptance is not more than 10%. Other than traditional or multiple mini-interview, depending on the university, there is the United Kingdom Clinical Aptitude Test (UKCAT) required by most universities and Biomedical Admission Test (BMAT) required by five universities. The medical courses in English medical schools are “problem-based learning” and “lecture-based learning”, and consist of 2-3 years in pre-clinical and 3 years in clinical. The graduates after these 5-6 years of medical training are recognized as Foundation House officer (FHO) and are only permitted to work in supervised clinics and hospitals for one year before being granted independent license to practice as GP and fully register in the General Medical Council. (6-7)
Which system is better?
Is the straight entry from high school to medical school better or an entry after a four years under-grad university education? While entry into medical school in most parts of the world is probably the hardest among any other university courses, when entered most students graduate and there is not much scrutiny and not much failure. A major difference between the two systems is the age and maturity of the applicant. In the straight from high school entry with 6 years course, the applicant is younger and less mature, but in the other system entry after a bachelor degree, the applicant is four years older and more mature. At the same time in the first system of straight six years medical studies, two years basic medical sciences and four years of clinical, the students acquire more knowledge due to studying medicine two years longer. But in the four years course after a bachelor degree, unless those students who have studied four years of basic medical sciences, the rest have only four years to study medicine, including basic and clinical sciences. That is why in countries with this latter system such as US and Canada, there is no GP or licensure to practice after graduation from medical school, unless finishing a specialty training that equivalent to general practice is family practice in these countries that require an additional two years of training. At the end both system in regard with training, education and knowledge could be equivalent, but the only difference will remain age and maturity that the latter system could provide more better health care service due to age and maturity.(8-9)
Are the licensing examinations well justified?
In US and Canada where they have the toughest system of entry into medical specialty and residency training, particularly for the foreign medical graduates who seeking abundantly for practicing medicine in these two countries, there are long and laboring examination processes. Eight hours of examination by Medical Council of Canada and 33 hours of examination by the USLME, while most questions could be repetition of previous exams and accessible or leaking to the candidates from their questions bank, seem to be redundant. The assessment of medical knowledge through multiple choice questions, and even mock clinical scenarios by simulating patients are all still questionable in the real evaluation of the candidates. Perhaps shortening these examinations, securing the questions bank or eliminating it totally and posing new questions based on the new knowledge in medicine, and also evaluating the passing candidates at the first level of these short exams, over a period of time 6 months-one year in clinical setting would serve more the purpose.
Under-developed and Developed Medical Educations
Like the world itself that has been divided into developed and under-developed based on the unfair distribution of capital and wealth, the medical schools and education are unfairly distributed across the globe. For example, the Caribbean region, with a total population of less than 40 million, has 54 operating medical schools, while of the 57 African nations, 16 did not have a single medical school. (6-7)
What about continuing medical education?
In some countries such as US and Canada, the physicians past their graduation and licensure, they are still required continue with their medical education and upgrading their medical knowledge of the new research findings and new treatment strategies and guidelines. While this mandatory continuing medical education is well justified, but mostly is done passively and through attending medical conferences, that have become another business venture and source of profit making by the organizers. Moreover there are no quality control or measurement of the learning of the physicians attending these conferences, as documentation of spending certain hours of attendance of these conferences satisfy the medical licensing authorities. At the same time pharmaceutical or medical tools and equipments companies are very influential on the continuing education of the physicians, to promote their products.
What to do?
Medical profession has been regarded the highest career and position throughout history of mankind, and physicians have always been standing alongside or just one step lower of religious authorities. Being physician has always been respected by the public at large and many countries not as a business but a holy career and position. This has been so as the lives of people are the highest priority for everyone everywhere. In other word society puts the lives of their subjects at the hands of physicians who can save or hasten end of lives. Therefore the training of physicians and medical education need to be a vital priority, respected and well protected away from any capital, social, economical and political enterprises.
Since human illnesses are like problems need to be solved by physicians, the process of the causation of the illnesses, or their pathophysiology need to be the utmost important part of the medical training of the medical students. Therefore any chapter on the etiologies or causes of the illnesses that still exist in the medical textbooks should be erased and chapters on the pathophysiology of each illness be added. The difference is that etiology and cause, even if true never explains the process or steps to the causation and development of a disease, which is dynamic. The emphasis on the pathophysiology of the illnesses as the first priority, will lead the medical students and physicians in a path of thinking and understanding of the illness causation and development, then problem solving and treatment. More importantly the medical education based on pathophysiology of the illnesses, will lead us to the future of medicine that should be preventive and not treatment based.
The current treatment based medicine that exist all over the world, even in the developed countries is basically treatment with medications and surgical procedures. This old method of medicine that could easily been applied even by a pharmacist and by a very short medical training will never understand the causative processes of illness and will not add much to the longevity and overall well-being of man kind, but perhaps adds to the profit making of capital enterprises such as pharmaceutical companies. Too much emphasis of treatment and not prevention has led to symptomatic treatments of not illnesses that is per se treatment of symptom by symptom without treating the disease at heart. For example pain killers or analgesics and cold medicines have become such a huge market of capital gain as they are sold over-counter without any medical advise and in fact advertised all over media and encouraged their use by the public. These symptomatic treatments often impede the proper treatment processes as covers the surfacing symptoms that are alarming signals, while the process of disease continues and impinge or ends lives. On this venture, naturopathic medicine has invested immensely by selling their non-scientifically studied and proven products, such as vitamins, minerals, and supplements based on the propaganda of being naturals and not chemicals.
Our current and already well due medicine based on the etiology and not pathophysiology, has also been predominant in the medical research as most studies are treatment based and sponsored by pharmaceutical companies. Even studies on the etiology of the illness, are mostly based on a cause-and-effect formula and concept. For example recognizing a genetic cause to a disease that is very common in the medical literature, is based on such simple mentality and so far has not been yielding anywhere. Genetics are not causes of illnesses, but mediators and even that at the most would not go beyond 25-30% of any illnesses, even cancers or autoimmune disorders. Even this low rate of link, not causation is more sophisticated than searching for a single mendelian gene that many medical researches looking for and many such papers are still yearly published. On the subject of genetic causes of the diseases, that is mostly understood and mistaken with “hereditary”, it has been rarely questioned that how the first person in a hereditary line was affected, before the existence of any genetic line of disease in a single family.
Pathophysiologic basis of medicine, hence the medical training, for example seeks and explains the causative processes of the hereditary illnesses, such as mutations in our genetic lines. The knowledge that genes are templates to pass on the species or hereditary lines and are innately evolutionary and protective per law of survival, and when diseased, they have been intercepted by an external invasion through mutation, is one basis of pathophysiologic process of medical illnesses. Lastly the current medical knowledge and education based on the cause-and-effect holds a a narrow and short-term vision of the causation of illnesses. This method only could explain superficially the acute illness, not the chronic and laden conditions, e.g. cancers and autoimmune disorders, or our genetic changes and mutations, evolved over time by epigenetic factors. The future of medical training and the whole medicine need to change based on the pathophysiologic understanding of the illnesses, hence paving the path towards the preventive medicine.
The medical training and education around the world was briefly reviewed, with more focus on the advanced and more sophisticated systems of developed countries such as US, Canada and UK. The medical licensing bodies all over the world create many steps of examinations in selecting the best candidates for their medical treatment programs, particularly in medical specialties, and more so in the developed countries, but there is not much progress in the prevention and treatment of life-costing illnesses such as cancers and autoimmune disorders. Testing the candidates in the medical disciplines over hours and hours on medical knowledge that is usually parrot-like memorized is not the solution and would not guarantee to select the best candidates and train the best physicians.
Some medical schools specially in the developed nations, have focused their training on problem-solving and case approach models, but until we found the medical training that is currently on a cause-and effect model to to a pathophysiologic model, nothing much could be achieved. This perhaps needs to be changed and revolutionized first in the medical research field as it is still predominant by the cause-and effect model, that leads quickly to a hasty treatment approaches mostly with medications, benefitting pharmaceutical companies, without having a solid understanding of the underlying pathophysiology of diseases. The medical education, research all need to move towards a better understanding and explanation of the underlying mechanisms of illness causation, that are not often very simple, like to formula of A->B, or being justified by simple genetic excuses, but an interaction between the organism and the environment, and in case of genetics, on a epigenetic model. This revolutionary path if taken on, will soon lead us to prevention of many life-threatening and shortening human illness.
Dr.Mostafa Showraki, MD, FRCPC
Lecturer, School of Medicine, University of Toronto
Author: ADHD: Revisited Book, Amazon Kindle Books
1.World Health Organization. 2000. World directory of medical schools. 7.Geneva, WHO.
2.World Health Organization. 2004. Medical school updates, world directory of medical schools: Supplemental information. Geneva:WHO.
3.Foundation for Advancement of International Medical Education and Research. 2005. International medical education directory. IMED FAIMER. Available at: http://imed.ecfmg.org (accessed 20 April 2006).
4.Institute for International Medical Education. 2005. Database of medical schools 2005 IIME. Available at: http://www.iime.org/database(accessed 20 April 2006).
5.International Federation of Medical Students’ Associations. 2005. Curriculum database IFMSA. Available at: http://www.ifmsa.net/public (accessed 13 April 2006).
6.Boulet J, Bede C, McKinley D, Norcini J. An overview of the world’s medical schools. Med Teach. 2007 Feb;29(1):20-6.
7.Duvivier RJ, Boulet JR, Opalek A, van Zanten M, Norcini J. Overview of the world’s medical schools: an update.Med Educ. 2014 Sep;48(9):860-9.
8.Eckhert NL. 2002. The global pipeline: too narrow, too wide or just right? Med Educ 36:606–613.
- Cooper RA. 2005. Physician migration: A challenge for America, a challenge for the world. J Continuing Educ Health Professions 25:8–14.
- Mullan F. 2006. Doctors for the world: Indian physician emigration. Health Affairs (Millwood) 25:380–393.